BILL ANALYSIS Ó
AB 2348
Page 1
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
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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."
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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