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Published: September 29, 2020

Governor Signs Bill Allowing NP Independent Practice

This week, Governor Gavin Newsom signed AB 890 (Wood), which creates a pathway for nurse practitioners (NPs) to practice without physician supervision. Despite an outstanding effort by CAFP’s Government Relations team and family physicians throughout the state, the Legislature passed the bill in the final minutes of session. CAFP remains concerned that the new law lacks sufficient patient safety guardrails and ignores access to care concerns. This bill will now undergo a regulator process in which care standards and education requirements will be determined. CAFP has already begun the process to fight to ensure those standards and requirements are stringent enough to protect patients and, to the extent possible, limit the creation of two tiers of care.

Aside from the serious health and fiscal consequences create by COVID-19, the pandemic also wreaked havoc on the Legislative Session – multiple legislators tested positive for the virus, the halls of the capital were closed to the public, virtual committee hearings were held, and remote voting was allowed in the State Senate. The pandemic also led legislators to change previous policy positions, leading to unexpected legislative outcomes. One of the biggest examples of this is AB 890. Some think the bill could change health care market dynamics across the state and create a two tired system of care. Others think very little will change. One change may be increased health care costs. As the experience of major health systems have shown, NPs prescribe and refer more than primary care physicians, driving up costs. Some fear that NP independent practice could lead to a further shortage of primary care physicians or change the nature of what services family physicians provide. Many worry that the insufficient training and oversight requirements for NPs to practice medicine will compromise the care patients receive.

Throughout committee hearings and floor sessions, CAFP focused its arguments against the bill on the lack of ongoing competency training in the bill, as well as its lack of provisions to require or even create incentives to increase care in rural and underserved areas. While the legislation was amended to delay implementation until January 2023, and added guidance on oversight, minimum qualifications, and physician collaboration AB 890 still falls woefully short of meeting CAFP’s Principles on the Independent Practice of Medicine by Nurse Practitioners.

Oversight

While oversight of NPs will continue to be the responsibility of the Nursing Board, the bill creates a Nurse Practitioner Advisory Committee consisting of four NPs, two physicians, and one member of the public. The Committee will advise and make recommendations on all matters relating to NPs, including, but not limited to, education, standards of care, and disciplinary action against an NP.

Individual Requirements

An NP could practice independently if they meet all of the following criteria:

  • Pass a national certification examination
  • Complete a Transition to Practice program – a minimum of three full-time equivalent years of practice/4600 hours of clinical experience and mentorship provided to prepare a nurse practitioner to practice independently, including but not limited to, managing a panel of patients, working in a complex health care setting, interpersonal communication, interpersonal collaboration and team-based care, professionalism, and business management of a practice.
  • Have practiced as a nurse practitioner in good standing for at least three years, not inclusive of the transition to practice.
  • Maintain professional liability insurance.
  • Verbally inform all new patients that the NP is not a physician
  • Post a notice in a conspicuous location accessible to public that the NP is regulated by the Board of Registered Nursing, including the board’s telephone number and website.

Online educational programs that do not include mandatory clinical hours will not meet these requirements.

Collaboration Requirements

An NP must establish a plan for referral of complex medical cases and emergencies to a physician or other appropriate health professional. Physician consultation specifically must be obtained when:

  • Emergent conditions require prompt medical intervention after initial stabilizing care has been started.
  • Acute decompensation of patient situation exists.
  • A problem has not resolved as anticipated.
  • A history, physical, or lab findings are inconsistent with the clinical perspective.
  • If the patient requests it.

Up Next: Regulations

The next step in this process is the Nursing Board creating regulations governing how an NP becomes independent and how an independent NPs can practice. There will need to be considerable work done around defining what is included in the required “Transition to Practice” program. CAFP has already begun the process of gathering with interested stakeholders to direct our regulatory advocacy to address the issues not solved in AB 890, particularly requiring ongoing competency training similar to that which physicians must undergo to practice medicine independently.

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