Feeble cheer for California’s nurse practitioners

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Nurse practitioners fill an important role in the health system by increasing the number of providers who can prescribe medications and treat more routine health issues. Faced with projections of huge shortfalls of up to 124,000 in primary care providers over the next decade, experts frequently encourage states to adjust nurse practitioner laws to meet the needs of the population. Despite being highly educated and well-trained, stringent regulations frequently prohibit nurse practitioners from independently providing care to the extent of their abilities.

Unsurprisingly, California has historically been among the most restrictive states in the nation when it comes to nurse practitioners’ independence. But starting January 1, 2023, nurse practitioners can finally work toward receiving “full-practice” authorization in California as AB 890 (2020)  comes into effect.

While the text of the legislation states that it, “shall not be an undue or unnecessary burden to licensure or practice,” a closer look reveals that some of the new requirements do just that.

Three main issues in the requirements persist.

Restriction 1: Lack of “Grandfather” Provisions

As part of the law, nurse practitioners or NPs can be divided into two new classes. Starting in the new year, nurse practitioners can apply to the first class which allows nurse practitioners to work without contractual supervision by a physician, but still requires at least one doctor or surgeon to be present on-site.

Once a nurse practitioner has achieved at least three years of full-time clinical experience (or 4,600 hours of experience within the last five years) they can then apply to the second class. The second class allows nurse practitioners to open their own clinics. But with this tiered approach, Californian nurse practitioners will not receive full-practice authority until at least 2026six years after Governor Newsom signed the new law. Currently, 28 states allow nurse practitioners to have full-practice authority, 22 do not. With the implementation of AB 890, California will become a state that allows full-practice authority.

Simply requiring a doctor on-site for nurse practitioners is a great step in the right direction. However, many nurse practitioners have worked in California under supervision for many years. The Nurse Practitioner Advisory Committee (the group who proposes the rules) would be wise to “grandfather in” nurse practitioners with significant experience by allowing them to apply immediately to the second class starting in 2023.

Just as doctors are required to complete clinical training to gain “real-world” experience before practicing independently, requiring nurse practitioners to have at least 4600 hours of supervised practice is important to ensure patient safety. But considering the dangers presented by our state’s growing doctor shortage (especially as exemplified by the pandemic), preventing highly experienced nurse practitioners who meet or exceed the three-year requirement would be detrimental to all Californians.

Additionally, rather than allowing doctors to spend time with those patients who need assistance, the bill keeps doctors focused on managing nurse practitioners.

Restriction 2: Only allows California Experience

Included within the time requirement, the experience provision only counts if it was acquired in California. While this might make some sense as minor standards differ by state, there may be unintended consequences from the restriction.

Of the Western states, California is the only state without independent practicing nurse practitioners. In other states, nurse practitioners have had their own clinics for years.

Requiring experience to be in California discourages nurse practitioners from other states – especially individuals who reside closest to California geographically – from coming here to work. Working under a doctor again could be viewed as taking a step back in one’s career.

To encourage nurse practitioners to come to California, the committee should consider allowing nurse practitioners with sufficient expertise and experience earned in other states to apply directly to the second class.

Restriction 3: Creates a Redundant California Test

The American Association of Nurse Practitioners (AANP) disapproves of AB 890, citing concerns of over-regulation.

One criticism is that the requirements create a new state-based certification exam for nurse practitioners. AANP CEO David Herbert commented, “National board certification exams are the gold standard…creating a unique California exam would be a duplicative and costly process.”

The national test is well-established and recognized by the federal government and other jurisdictions. As Herbert said, creating a state-based test is “the epitome of unnecessary regulation.”

Not only is the California test redundant, but it has not yet been created. Nurse practitioners may not know exactly what is required to pass the test.

While AB 890 is a step in the right direction…it is a small step. If California truly intends to allow nurse practitioners independence to meet current healthcare demands, more deregulation is necessary.

McKenzie Richards is a policy associate at the Pacific Research Institute.

Nothing contained in this blog is to be construed as necessarily reflecting the views of the Pacific Research Institute or as an attempt to thwart or aid the passage of any legislation.

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