Robust growth in earnings over time for an occupation can provide evidence that demand for the services provided by members of the occupation exceeds supply. Rosenstein, Melissa G., Malini Nijagal, Sanae Nakagawa, Steven E. Gregorich, and Miriam Kuppermann. In 39 states, there are limits on the number of physician assistants a physician can supervise or with whom a physician can collaborate. 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. 1998. First, we discuss the likely impacts on safety and quality of the states physiciansupervision requirement for nurse midwives, given the specifics of the states requirement and how it is implemented in practice. 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. 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. Historically, NPs in California have been required to work under the supervision of a physician a major hurdle in rural communities that attract and retain few doctors, Curtis said. Waiver of NP and CNM Supervision Requirements In the Order Waiving Nurse Practitioner Supervision Requirements , the DCA waives the limitation under B&P Code Section 2836.1(e) that a supervising physician may supervise, at any one time, only up to four NPs who are furnishing or ordering . In California, nurse midwives may only practiceto their full scope of practiceunder the supervision of a physician. As noted earlier, we believe this issue might be limiting access to nursemidwife services in the state, and potentially to womens health care services more broadly. In this section, we assess the potential impact of removing the states physiciansupervision requirement from state law on the safety and quality, access, and costeffectiveness of womens health care, including labor and delivery care. Due to the flexibility of Californias physiciansupervision requirement, described above, we find that Californias requirement is unlikely to be any more effective than other states similar requirements at improving safety and quality. Nurse midwives are required to immediately refer women experiencing complications during childbirth to a physician. Eligibility requirements for physicians and physician assistants: In the previous section, we discussed the theoretical and practical reasons for how Californias physiciansupervision requirement could limit access to nursemidwife servicesand potentially womens health care services more broadly. Figure7 summarizes our assessment of academic research findings as they pertain to the care provided by nurse midwives and physicians, mostly in hospital settings. 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. A physician could have up to eight (8) mid-level practitioners (4 APRN's and 4 PA's) at one time. Nurse Midwives Employ Fewer Costly Labor and Delivery Interventions Than Physicians. However, in our review of the research literature, we found less conclusive and more mixed evidence of the safety and quality of care in other settings where nurse midwives practice commonly. . 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. We note that these studies primarily compare nursemidwife and physician care in hospital settings. Authority has been delegated by the supervising physician to provide the covered benefit or service pursuant to their scope of practice. During the 2019 Colorado legislative session, House Bill 19-1095 was passed, which established requirements for the supervision of PAs in the Medical Practice Act (MPA). "the circumstances and provide written verification of physician availability for consultation, referral, or direct medical intervention in emergencies, and after hours, if indicated." (Ala. Admin. State law; 3. https://doi.org/10.1016/j.midw.2018.03.024. (4) The supervising physician shall provide a copy of the signed, written authorization to the nurse practitioner or nurse midwife. Currently, 40 states delineate a maximum number of physician assistants a physician may supervise at one time. The practice would much prefer more MDs as well because if youre not supervising others you can see more patients. Potentially Positive Impact on Safety and Quality in Hospital Settings, the Most Common Setting for Childbirth. (Minimum of 5% of the PAs medical records). These high training costs likely are compensated within the health care system through higher incomes for physicians, ultimately leading to higher womens health care costs overall than they would otherwise be. Nurse midwives are allowed to practice and are active in all 50 states. "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. Physician extender (PE) is a term applied to midlevel professionals who work under the supervision of a physician and carry out functions within the scope of the physician's practice. Next, we summarize national research findings related to the safety, quality, and relative costeffectiveness of care by nurse midwives, as well as how occupational restrictions affect access to their services. Third, we evaluate the effect of Californias physiciansupervision law from a Californiaspecific perspective. 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. Why in the world are you guys agreeing to supervise midlevels?? four (4) and the maximum of PA's in a solo practice is two (2). Mid-level practitioners include CRNPs, CNMs and PAs. [1] The law brings California in line with over half of the states in the U.S. by permitting NPs to practice independently and to the full extent of their training and education. Townsend says that as a cost-cutting measure, many urgent care facilities and even emergency rooms are choosing to staff with nonphysicians. 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. CostEffective: Effectiveness or value in terms of safety, quality, and accessibility of health care in relation to the costs of such care. Enacting policies to increase access to nursemidwife services could increase access to womens health care services, generally maintain safety and quality, and lower costs. Theres always an MD designated as on call and the go to person for questions. 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. Nurse Midwives Comprise an Appreciable Share of the Womens Health Care Workforce in California There are over 2,000 OBGYNs in California, compared to more than 700 nurse midwives and almost 400 licensed midwives. https://doi.org/10.1111/birt.12464. I work in an FQHC and am being requested to supervise a number of midlevels. The risk is that a plaintiff (injured patient) can . 2015. Other key factors, such as OBGYNs ability to provide care in complex caseswhich derives from their more extensive trainingalso likely contribute to their higher incomes. First, and most directly, nurse midwives unable to obtain statutorily required physician supervision may not establish independent practices through which patients could obtain care. 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. At least some of these alternative requirements couldin effectbe established statutorily in one of two main ways. We note that since these studies are observational as opposed to experimental in nature, whether fewer occupational restrictions actually cause an increase in the number of practicing nurse midwives, or if other factors explain the identified relationship, is uncertain. OBGYNs and nurse midwives overwhelmingly practice in hospitals, while licensed midwives primarily practice outside of hospital settings, such as freestanding birth centers. The encounter could then be billed under the physician. At the state level, because Californias requirement does not clearly define the responsibilities of supervision, the states requirement is unlikely to be more effective than other states similar requirements. Given the lack of differences at the national level for safety and quality between states with and without physician oversight requirements, Californias supervision requirement specifically likely does not significantly improve safety and quality for maternal and infant health. 2018. 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. Evidence from Nurse Practitioners and Physician Assistants.Journal of Health Economics33 (January):127. Vedam, Saraswathi, Kathrin Stoll, Marian MacDorman, Eugene Declercq, Renee Cramer, Melissa Cheyney, Timothy Fisher, Emma Butt, Y. Tony Yang, and Holly Powell Kennedy. (CCR 3502) As NP training becomes increasingly watered down, expect malpractice cases involving NPs to continue to increase (they already are). Immediate Referral to a Physician Is Required When Childbirth Complications Arise. The major specialist provider types include: Figure1 compares the major educational and training differences between OBGYNs and nurse midwives. Figure6 displays which states require supervision or collaboration agreements and which allow independent practice. Nurse Midwives Salaries Are Generally Lower Than OBGYNs. Nurse midwives have the authority under state law to furnish medications. This does not have to be a workflow constraint and can be done effectively and efficiently without distracting from the productivity improvements and cost efficiencies that mid-level providers bring to . 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