BILL ANALYSIS                                                                                                                                                                                                    



                                                                  AB 2348
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          Date of Hearing:   April 24, 2012

              ASSEMBLY COMMITTEE ON BUSINESS, PROFESSIONS AND CONSUMER 
                                     PROTECTION
                                 Mary Hayashi, Chair
                   AB 2348 (Mitchell) - As Amended:  March 29, 2012
           
          SUBJECT  :   Registered nurses: dispensation of drugs.

           SUMMARY  :   Allows registered nurses (RNs) to dispense hormonal 
          contraceptives in primary care clinics.  Specifically,  this 
          bill  :  

          1)Allows RNs to dispense drugs or devices upon an order by a 
            certified nurse-midwife (CNM), nurse practitioner (NP), or 
            physician assistant (PA) if the RN is functioning within a 
            licensed primary care clinic, as specified.

          2)Allows RNs to dispense hormonal contraceptives pursuant to 
            standardized procedures, developed in compliance with current 
            law defining standardized procedures that RN's may implement, 
            if the RN is functioning within a licensed primary care 
            clinic, as specified.

           EXISTING LAW  

          1)Regulates and licenses physicians and surgeons and PAs via the 
            Medical Board of California (MBC).

          2)Regulates and licenses RNs, including advanced practice nurses 
            in the categories of CNM or NP, via the Board of Registered 
            Nursing (BRN). 

          3)Allows RNs to dispense drugs or other devices upon an order by 
            a physician and surgeon if the RN is functioning within a 
            licensed primary care clinic, as specified.

          4)Defines "standardized procedures," as it pertains to RN's 
            scope of practice, to mean policies and protocols developed by 
            an organized health care system or a health facility licensed 
            by DPH, as specified, through collaboration among 
            administrators and health professionals, including physicians 
            and nurses.  These policies and protocols shall be subject to 
            any guidelines for standardized procedures that the Division 
            of Licensing of the MBC and the BRN may jointly promulgate.  








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            If promulgated, the guidelines shall be administered by the 
            BRN.

           FISCAL EFFECT  :   Unknown.  This bill is keyed non-fiscal.

           COMMENTS  :   

           Purpose of this bill  .  According to the author, "Across 
          California, many women lack access to birth control, leaving 
          them at significant risk of unintended pregnancy. In some parts 
          of the state, patients of community health clinics cannot access 
          hormonal contraceptives because of the limited supply of 
          prescribers and others who are legally authorized to order or 
          furnish these medications.  Lack of enough appropriate staff can 
          result in health centers closing or reducing hours, compounding 
          many communities' unmet family planning needs.  For a woman in 
          need of birth control these types of shortages can mean waiting 
          long periods of time to schedule a health center appointment, 
          sitting in a waiting room for hours before being seen, or 
          driving long distances to see a provider.  All of these barriers 
          place her at greater risk of unintended pregnancy."

           Background  .  The BRN regulates California RNs. There are more 
          than 300,000 RNs in California providing health care services in 
          a variety of settings.  RNs use a number of titles in their 
          practice, including certified nurse anesthetist, CNM, clinical 
          nurse specialist, critical care nurse, NP, and public health 
          nurse.

          Existing law allows RNs working in primary care clinics to 
          dispense drugs or other devices only upon an order by a 
          physician and surgeon.  This bill expands the number of 
          practitioners under whose orders an RN may dispense medications 
          to include CNMs, NPs, and PAs.

          This bill also allows RNs to dispense hormonal contraceptives 
          pursuant to standardized procedures as that term is defined in 
          existing law governing RN's scope of practice.

           Support  .  Planned Parenthood Affiliates of California, the 
          sponsor of this measure, writes, "Access to birth control is a 
          critical public health issue and an essential component of 
          women's health care.  Unfortunately, there are thousands of 
          women in California who lack access to contraception, leaving 
          them at significant risk of unintended pregnancy.  In fact, 








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          according to data from the Family PACT program evaluation, only 
          71% of women in need of publicly funded family planning services 
          are actually able to access care.  

          "In some parts of the state, this lack of access is due to 
          shortages of doctors and health care professionals authorized to 
          order or furnish these medications.  For example, Planned 
          Parenthood health centers in the Central Valley have ongoing 
          staff vacancies, which, if filled, would result in 13,000 more 
          patients receiving basic reproductive care each month.

          "Contraceptives are among the safest and most widely studied of 
          all drugs.  Due to this safety and the importance of timely 
          access, medical standards and guidelines currently recommend 
          that birth control be provided based on a self-reported medical 
          history and blood pressure check, delinking requirements for 
          annual pelvic examinations and PAP smear tests.  These updated 
          guidelines establish the current standard for care and expand 
          access to comprehensive reproductive care.  While preventive 
          screenings and well-woman visits are key to the quality 
          reproductive health care provided by Planned Parenthood, there 
          is no medical reason to delay providing access to birth control 
          until a woman has undergone them."

           Opposition  .  The California Association for Nurse Practitioners 
          states, "AB 2348 would remove NPs from the medical examination 
          and assessment of patients prior to the dispensation of hormonal 
          contraceptives.  However, under the regulatory scenario proposed 
          in (this) bill, NPs would be held ultimately responsible for the 
          decisions made by the RN?we believe that AB 2348 would put the 
          NP in the middle of a legal relationship between a physician, an 
          RN, and a patient, without having seen the patient.

          "While many forms of hormonal contraception are very safe, all 
          patients should undergo a medical assessment with a provider who 
          is able to review their potential risk factors, family history, 
          and other medical factors and then make an informed 
          determination as to a medication they may be taking.  To perform 
          this type of assessment is beyond the current scope of practice 
          of an RN?Should complications arise, it is unclear to us what 
          options the patient would have to maintain an ongoing 
          relationship with her provider.

          "RNs are not currently authorized to furnish or prescribe.  
          Again, it concerns us that the intent of AB 2348 is for an NP to 








                                                                  AB 2348
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          delegate his or her authority to dispense, and perhaps furnish, 
          to an RN who does not have this authority under existing law.  
          AB 2348 would allow for all types of hormonal contraceptives to 
          be dispensed by an RN, encompassing a very broad category of 
          drugs and devices, all of which require a prescription.

          "Lastly, our NPs who have reviewed the bill believe that AB 2348 
          is unnecessary.  Under current law, an RN may work under 
          standardized procedures.  Thus, the medical director could set 
          up these procedures and delegate authority directly to an RN to 
          dispense hormonal contraceptives."

          The California Nurses Association states, "Understanding the 
          difference between 'furnish' and 'dispense' is central to 
          understanding part of CNA's strong objections to this 
          legislation.  Under current law, RNs are allowed in primary, 
          community and free clinics to 'dispense' medications.  Dispense 
          means to hand to a patient for future use, medication prescribed 
          by a physician.  Under current law, NPs 'furnish' medications 
          under a professional protocol that is called 'standardized 
          procedure.'  Medication that is ordered for patients under 
          standardized procedures is referred to as 'furnishing' because 
          it is prescriptive authority that is delegated by physicians 
          under these special procedures/protocols.  NPs have advanced 
          training and an advanced degree to provide primary health care 
          and to 'furnish' medications.  NPs must have furnishing numbers 
          in order to verify that they have completed statutorily required 
          education to furnish medications under California law and that 
          furnish number must be printed on the order for medication that 
          is to be filled by a pharmacist.

          "This legislation refers to the new authority as the 
          'dispensing' of hormonal contraceptives but in actuality the RN 
          alone performs a nursing assessment and then under the mechanism 
          of a standardized procedure decides what contraceptive is 
          appropriate.  The RN then gives the patient the contraceptive 
          when the patient leaves the clinic.  There would be no 
          examination performed by a physician or a NP.  The 'dispensing' 
          of hormonal contraceptive is in actuality limited 'furnishing' 
          authority.  The only difference is that the patient does not get 
          a written order that can be filled at a pharmacy.  Instead, the 
          patient is handed the supply of medications that has been 
          determined by the RN to be appropriate for a particular 
          patient." 









                                                                  AB 2348
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           REGISTERED SUPPORT / OPPOSITION  :   

           Support 
           
          California Family Health Council (sponsor)
          Planned Parenthood Affiliates of California (sponsor)
          Planned Parenthood Mar Monte (sponsor)
          Planned Parenthood of Santa Barbara, Ventura and San Luis Obispo 
          Counties, Inc. (sponsor)
          Planned Parenthood Pasadena and San Gabriel Valley (sponsor)
          Planned Parenthood Shasta Pacific Action Fund (sponsor)
          Six Rivers Planned Parenthood (sponsor)
          ACCESS Women's Health Justice
          California Latinas for Reproductive Justice
          Forward Together
          Ibis Reproductive Health
          Law Students for Reproductive Justice
          Maternal and Child Health Access
          National Center for Youth Law
          National Council of Jewish Women
          Nevada County Citizens for Choice
          Physicians for Reproductive Choice and Health
          United Nurses Associations of California/Union of Health Care 
          Professionals
          Women's Community Clinic

           Opposition 
           
          California Association for Nurse Practitioners
          California Nurses Association
           
          Analysis Prepared by  :    Angela Mapp / B.,P. & C.P. / (916) 
          319-3301