By Ana B. Ibarra for CalMatters
California’s nursing agency this week approved rules that will allow nurse practitioners to treat patients without physician supervision. It’s a move that aims to expand access to care in the Golden State at a time when workforce shortages plague just about every corner of health care.
Monday’s vote is one of the last major steps necessary to fully implement a 2020 law that will allow nurse practitioners to practice more freely. Nurse practitioners, who have advanced degrees and training, currently must enter into a written agreement with a physician who oversees their work with patients.
Despite some earlier concerns about potential delays, nurse practitioners say they are now confident that applications to start the certification process will go live early in the new year as planned.
“Hopefully we don’t crash the website, but we are very excited,” said Cynthia Jovanov, president of the California Association of Nurse Practitioners. “This means that if I want to do a mobile clinic in Skid Row, I don’t have to be held hostage by paperwork to get a partnering physician who may not have the same desire.”
Nurse practitioners are a cost-effective way of bringing more primary care providers to communities that need them, particularly in rural areas, said Glenn Melnick, a health economist at the University of Southern California.
“And that can benefit the consumer as long as the quality of care is acceptable,” he said. Still, there are a limited number of them.
Nurse practitioners in California have been fighting to break free of physician oversight for years. The biggest pushback came from physicians. During legislative debate, the California Medical Association said nurse practitioners have less training than physicians, so allowing them to practice independently could lessen the quality of care and even pose a risk to patients.
Law is not “carte blanche”
In 2020, Gov. Gavin Newsom signed into law Assembly Bill 890, which was authored by Assemblymember Jim Wood, a Santa Rosa Democrat. To go into full effect, the Board of Registered Nursing had to first iron out details, including how nurse practitioners would transition into their more independent role and what type of additional training or testing, if any, would be needed to obtain certification.
The law essentially created two new categories of nurse practitioners. Starting in January, nurse practitioners who have completed 4,600 hours or three years of full-time clinical practice in California can apply for the first category. This first step will allow them to work without contractual physician supervision, but only in certain facilities where at least one doctor or surgeon also practices. The idea is nurse practitioners would still be able to consult a doctor when needed.
“So that does not give them (nurse practitioners) the carte blanche that I think some people were fearful of,” said Loretta Melby, executive officer of the state’s Board of Registered Nursing, during Monday’s meeting. “And then, when they are there for three years in that group setting with a physician or surgeon, only then can they advance to the (second category).”
This second designation will allow nurse practitioners full practice authority, without any setting restrictions. And in theory, nurse practitioners would be able to open their own medical practice. Given the phased-in approach, eligible nurse practitioners will likely obtain full independence around January of 2026.
California’s requirements for nurse practitioners to transition into full independence will be among the most robust in the country, according to one analysis by the California Health Care Foundation.
Nurse practitioners can perform physical exams, order lab tests, diagnose ailments and prescribe medication, but in California it had to be under the oversight of a doctor. Of the 31,000 nurse practitioners in California, an estimated 20,000 will be eligible to apply for expanded authority in 2023, according to the California Association of Nurse Practitioners.
Kenny Chen, a family nurse practitioner in South Central Los Angeles, exemplifies the type of clinicians researchers say California needs more of: He is interested in primary care; he speaks multiple languages, including Spanish and his native Mandarin; and he enjoys working with underserved populations.
Chen said that while he doesn’t expect major changes to his current role at Martin Luther King, Jr. Outpatient Center, the new law would allow his clinic to hire more nurse practitioners without having to meet physician-to-nurse practitioner ratios. “It can be very difficult to recruit physicians to come work in South Central LA,” Chen said.
Giving nurse practitioners more authority, he said, can also attract more of them to California. All other western states, for example, already allow nurse practitioners greater independence. California’s restrictions could be a deterrence, he said.
Ahead of Monday’s vote, the California Medical Association sent a letter to the Board of Registered Nursing stating that the nursing board’s rules for nurse practitioners to transition into their independent roles lacked clarity and didn’t provide any more meaningful guidance than what was already stated in the text of the law.
Melby, the nursing board’s executive officer, said she has also heard concerns that the law would expand the scope of services that nurse practitioners can provide, but clarified that the law doesn’t actually change the type of work nurse practitioners will be doing.
“What was updated was the supervision requirement,” Melby said. “And so it’s not like the nurse practitioner is now going to have the freedom to go out and perform surgery; that has never been a nurse practitioner scope of practice.”
New rules may increase health care access
According to workforce researchers, allowing nurse practitioners more flexibility is a small but key piece of the puzzle in alleviating California’s provider shortage.
Even prior to the pandemic, California was experiencing a shortage of medical providers. A 2019 report by a commission of health care experts estimated that by 2030, the state would need an additional 4,100 primary care clinicians. About 7 million Californians already live in provider shortage areas with a need for primary, mental and dental care, according to the report.
Rural counties tend to have the greatest shortages — in counties like Glenn, Trinity, San Benito and Imperial, more than 80% of people live without sufficient access to care. And when patients do find care, they often rely on nurse practitioners. Some studies have shown that although physicians still make up the biggest proportion of primary care providers in rural areas, nurse practitioners are choosing to work in rural settings at a faster rate.
Alexa Curtis, a family and psychiatric mental health nurse practitioner at a substance use disorder facility in Nevada County, said the need in rural communities has driven most of her career. Curtis, who is also an associate dean at the School of Nursing at the University of San Francisco, plans to develop a rural street medicine program with a focus on unhoused people with mental health needs and substance use disorders.
Once she is granted greater authority, “I will be able to pursue that goal without the barrier and expense of needing to secure a physician supervisor,” she said.
But working with other types of providers, including physicians, will always be part of her practice. “It is how we are trained and how we function as nurse practitioners,” she said.
Earlier this year, Newsom also signed into law Senate Bill 1375, which authorizes nurse practitioners to provide reproductive care and first trimester abortions without doctor supervision.
These two wins were huge for nurse practitioners, said Jovanov, the president of the nurse practitioner lobby. “I can tell you that this will lead to many more bills for regulations that need to change. We’re on this momentum and that is really exciting.”