Analysis of California’s Physician-Supervision Requirement for Certified Nurse Midwives

Analysis of California’s Physician-Supervision Requirement for Certified Nurse Midwives GABRIEL PETEK LEGISLATIVE ANALYST MARCH 11, 2020 analysis full gutter AN LAO REPORT LEGISLATIVE ANALYST’S OFFICE analysis full gutter AN LAO REPORT Executive Summary Women’s Health Care Providers Include Nurse Midwives. Three types of providers specialize in health care related to childbirth and women’s reproductive health. They are obstetricians and gynecologists (OB-GYNs), nurse midwives, and licensed midwives. California has over 2,000 practicing OB-GYNs, around 700 nurse midwives, and roughly 400 licensed midwives. OB-GYNs and nurse midwives overwhelmingly practice in hospitals, while licensed midwives primarily practice outside of hospital settings, such as freestanding birth centers. Nurse midwives and licensed midwives are authorized to be the exclusive attendant in cases of normal childbirth but are not authorized to be the exclusive attendant of high-risk births, such as those involving twins and those delivered by mechanical or surgical means. California Is Among 23 States to Require Physician Oversight of Nurse Midwives. Under California state law, nurse midwives may only practice and deliver health care services under the supervision of a licensed physician. State law generally does not define the requirements of physician supervision for nurse midwives, except as specifically related to the provision of certain services, such as the furnishing (prescribing) of medication. (State law also specifies that physician supervision does not require the physical presence of the physician.) While only four states (including California) require physician supervision of nurse midwives, an additional 19 states have similar requirements that nurse midwives maintain “collaboration agreements” with physicians in order to practice. Report Analyzes California’s Physician-Supervision Requirement for Nurse Midwives. California’s physician-supervision requirement for nurse midwives is intended to improve the safety and quality of women’s health care. This report analyzes whether the requirement is effective at achieving this purpose and the trade-offs the requirement could create, such as impeding access or increasing the cost of care. The findings of this report only are intended to apply to nurse midwives, not licensed midwives, who currently are not subject to a physician-supervision requirement. Physician-Supervision Requirement Unlikely to Significantly Improve Safety and Quality. Following our review of academic literature, we do not find evidence that the safety and quality of maternal and infant health care by nurse midwives is inferior to that of physicians in cases of low-risk pregnancies and births. Moreover, states with physician-supervision or collaboration-agreement requirements do not have superior maternal and infant health outcomes than states without such requirements. At the state level, because California’s requirement does not clearly define the responsibilities of supervision, the state’s requirement is unlikely to be more effective than other states’ similar requirements. Therefore, we find that California’s supervision requirement for nurse midwives is unlikely to improve safety and quality for low-risk pregnancies and births. Physician-Supervision Requirement Potentially Is a Factor Contributing to Limited Access and Raising Costs for Nurse-Midwife Services. We find some evidence that access to nurse-midwife services specifically, and women’s health care services generally, might be limited in California. For example, the recent high growth in earnings for nurse midwives suggests that demand for their services may exceed supply. We also find evidence of geographic disparities across the state in access to care by OB-GYNs. We agree with the Federal Trade Commission’s finding that physician-supervision requirements likely impede access and raise costs by giving www.lao.ca.gov 1 analysis full gutter AN LAO REPORT physicians control over nurse midwives’ ability to independently deliver services. Moreover, on the national level, research shows that states without occupational restrictions on nurse midwives, such as physician oversight, tend to have greater access to nurse-midwife services. Removing Physician-Supervision Requirement Could Increase Access and Promote Cost-Effectiveness. Removing the state’s physician-supervision requirement could increase access to nurse-midwife services, including in the rural and inland areas of the state that today have relatively more limited access to women’s health care services. In addition, we find that removing the requirement could improve the cost-effectiveness of women’s health care services by increasing utilization of a less costly but capable provider and potentially lowering the medically unnecessary use of certain costly procedures, such as cesareans. Recommend the Legislature Consider Removing the Physician-Supervision Requirement, and Add Other Safeguards. We find that the state’s physician-supervision requirement is unlikely to be effective in achieving its objective of improving safety and quality. Moreover, we find that the requirement likely introduces trade-offs in terms of decreasing access and raising the cost of care. Accordingly, we recommend that the Legislature consider removing the state’s physician-supervision requirement for nurse midwives, while adding other alternative safeguards to ensure safety and quality. We believe these other safeguards could be more cost-effective than the state’s physician-supervision requirement at ensuring safety and quality. They could be imposed as conditions of licensure or as conditions to practice without supervision. Such safeguards could include requiring nurse midwives to: • Maintain appropriate referral and consultative relationships with physicians and potentially other providers. • Practice as a part of a health system (generally defined as a hospital, provider group, or health plan). • Practice in a licensed or accredited facility. • Maintain medical malpractice insurance. • Meet minimal clinical experience standards (such as a minimum number of years of practice) in order to practice without oversight. 2 LEGISLATIVE ANALYST’S OFFICE analysis full gutter AN LAO REPORT INTRODUCTION In an effort to ensure safety and quality, While we recognize that changes to other California state law places occupational licensing occupational licensing requirements on nurse restrictions on who may provide childbirth and midwives—such as their scope of practice—may reproductive-related health care services to bring certain benefits, we focus in this report on women. (Hereafter in this report, we refer to these the state’s physician-supervision requirement services as “women’s health care services.”) Three since its effects are likely more pronounced and specialist provider types are permitted, through better studied than other occupational licensing state licensure, to provide such services with high, requirements. The findings of this report are not if varying, degrees of autonomy: physicians, nurse expressly intended to extend to licensed midwives, midwives, and licensed midwives. Under current in large part due to the fact that licensed midwives state law, nurse midwives may only practice and can already practice without physician supervision deliver health care services under the supervision of under California state law. a licensed physician. In contrast to California, most Layout of the Report other states do not have a physician-supervision requirement for nurse midwives, and a majority This report contains three main sections. In of other states do not even have the requirement the first section, we provide background on the for nurse midwives to maintain collaboration various provider types that deliver women’s health agreements with a physician. care services, the major settings where these At the request of a member of the Legislature, services are provided, and how occupational this report analyzes the impact removing standards—such as licensure requirements— California’s current physician-supervision impact their practices. The second section of this requirement for nurse midwives would have report contains our analysis. It opens by laying out on health care outcomes and access to care the evaluation framework by which we assess the for mothers and their infant. In effect, we have state’s physician-supervision requirement for nurse been tasked with analyzing whether a specific midwives. Next, we summarize national research occupational licensing requirement for nurse findings related to the safety, quality, and relative midwives—in this case, the physician-supervision cost-effectiveness of care by nurse midwives, as requirement—is meeting its intended safety and well as how occupational restrictions affect access quality objectives without significantly decreasing to their services. We then assess the likely impact access to health care services (or increasing cost). of California’s physician-supervision requirement While providing primary care services is within the on—and how removing it may affect—the safety, scope of practice of nurse midwives, the focus of quality, accessibility, and relative cost-effectiveness this report—and the research we cite—is on the of nurse-midwife services. The last section of this care provided to women and their infants related report provides our concluding assessment and to pregnancy and childbirth. This focus reflects includes our recommendations. At the end of this the fact that such care is a primary focus of report, we include a selected references section nurse-midwives’ services and is the most complex that displays the major academic articles and other and risky care that they generally provide. reports that we relied upon in our analysis. www.lao.ca.gov 3 analysis full gutter AN LAO REPORT BACKGROUND State Law and Professional Societies Providers May Perform Services Within Their Scopes of Practice. Scope-of-practice rules Set Requirements for Who May establish the range of services and procedures Provide Health Care Services that a health care provider may perform under their State Licenses Health Care Providers. professional license, certification, or otherwise Through the licensing of providers, California state determined competencies. Some scope-of-practice law places restrictions on who may provide certain rules are established in state law while others kinds of health care services. The state issues are self-determined by individual health care distinct licenses for different types of health care systems and/or professional societies—such providers, including, for example, physicians and as the American Board of Family Medicine. The surgeons, dentists, and nurses. An individual who following bullets give a high-level summary of obtains a given license is permitted under law to how California’s scope-of-practice rules pertain to provide the services authorized under the license, physicians, nurses, and advanced practice nurses. while an individual without that license is prohibited • Physicians. In California state law, physicians’ from providing such services. scope to practice medicine and surgery is State Sets Licensure Standards. State rules unlimited. Accordingly, state law broadly establish minimum educational, clinical experience, authorizes physicians to diagnose mental and other standards in order for individuals to and physical health conditions, prescribe and become licensed health care providers. To receive administer medication, and perform surgery. a license to practice as a physician or a nurse, an In practice, however, physicians tend to individual must, among completing other steps, practice within the scope of their particular graduate from medical or nursing school, complete specialties. Physicians typically receive a qualified training program, and pass a series of national certification to practice within the licensing exams. various specialties. Additional Occupational Standards Are • Registered Nurses. The scope of practice in Effect Through Certification. Health care for registered nurses includes the provision providers—prospective or practicing—who wish of basic health care, such as observing the to perform in certain specialties regularly seek signs and symptoms of illness (but not its certification from nongovernmental agencies with diagnosis), delivering immunizations, and the intent of demonstrating their proficiency in drawing blood. Registered nurses generally those specialties or procedures. As with licensure, may administer medications and other to obtain certification, providers typically must therapies only as ordered by a physician or by meet minimum education and/or work experience another authorized provider. requirements and pass formal assessments such • Advanced Practice Nurses. Advanced as a qualification exam. In contrast with licensure, practice nurses are registered nurses who certification is often voluntary for individuals, have completed graduate-level (masters- or meaning that individuals who are not certified doctoral-level) nursing education. (In contrast, in a given specialty are still permitted under law registered nurses generally will have to perform in that specialty (as long as they are completed bachelor- or associates-level licensed, if required). However, health care systems, nursing education.) Nurse practitioners are such as hospitals and health insurers, regularly the most numerous type of advanced practice require—for a broad range of specialties—their nurses. Given their advanced education, providers to be certified in order to practice. advanced practice nurses have a more 4 LEGISLATIVE ANALYST’S OFFICE analysis full gutter AN LAO REPORT expansive scope of practice compared to services more broadly, several provider types registered nurses. For example, advanced specialize in this domain of care. The major practice nurses may diagnose patients, specialist provider types include: order tests, and “furnish” (broadly similar to • Obstetrician-Gynecologists (OB-GYNs). prescribe) medications. Unlike physicians, OB-GYNs are physicians who are certified however, advanced practice nurses’ scope to practice obstetrics and gynecology, which of practice are, in some cases, limited within are the surgical and medical specialties state law. In addition, for certain services, related to pregnancy, childbirth, and women’s California state law requires advanced reproductive health. practice nurses to practice in accordance with • Nurse Midwives. Nurse midwives are a standardized procedures, as developed in type of advanced practice nurse who are collaboration with physicians and the health certified to practice nurse midwifery—health systems in which they work. care related to women’s reproductive health, State Law Establishes Physician-Supervision pregnancy, and childbirth. Nurse midwives Requirements for Certain Types of Advanced must hold a graduate degree in nurse Practice Nurses. In California and other states, midwifery. They provide primary care and state law permits certain types of advanced assist, often without the physical presence practice nurses to practice, to their full scope, of a physician, in childbirth provided that the only under the supervision of a physician. By pregnancy is low risk and proceeds without “full scope of practice,” we mean delivering major complications. We discuss in detail the advanced practice nursing services, as opposed various occupational licensing restrictions that to the services delivered by a registered nurse apply to nurse midwives in California in the as ordered by a physician or other provider. How next section of this report. physician supervision is carried out in practice • Licensed Midwives. Licensed midwives are varies widely both across the country and within trained, non-nurse midwives who provide California. It generally involves (1) collaboration health care, including assistance during in the development and approval of standardized pregnancy and childbirth, to women and procedures, which advanced practice nurses their infants. Minimum licensing requirements generally are expected to follow in certain for licensed midwives include holding a high circumstances (such as prescribing medications), school diploma and completion of a qualified and (2) availability for consultation. In many cases, midwifery educational program that includes physician supervision additionally can involve “chart clinical training in pre- and postpartum care reviews” and/or other types of consultation whereby and labor management. the supervising physician reviews and advises upon advanced practice nurses’ patient care decisions Figure 1 (see next page) compares the major during and/or after patient treatment. Physician educational and training differences between supervision does not require the physical presence OB-GYNs and nurse midwives. In addition to the of the supervising physician while an advanced above-noted specialist providers, family practice practice nurse provides patient care. Given the physicians also regularly provide women’s health absence of a physical-presence requirement, in care services, with a small portion (according to California and other states, advanced practice national statistics) regularly attending childbirths. nurses may practice far away from their physician Family practice physicians are trained to deliver a supervisors. broad range of primary care services, including, but not limited to, women’s health care services. Women’s Health Care Providers Nurse Midwives Comprise an Appreciable Several Provider Types Specialize in Women’s Share of the Women’s Health Care Workforce Health Care. While a variety of provider types in California… There are over 2,000 OB-GYNs assist in childbirth and women’s health care in California, compared to more than 700 nurse www.lao.ca.gov 5 analysis full gutter AN LAO REPORT midwives and almost 400 licensed midwives. Women’s Health Care Settings As such, nurse midwives account for somewhat Women may receive primary care, family more than 20 percent of advanced health care planning, and labor and delivery services in a providers who specialize in women’s health care variety of settings. The following bullets briefly and childbirth. describe four settings that specialize in women’s …But Are Recorded as Attending a health care and detail how physician and Significantly Smaller Share of the State’s nurse-midwife services are utilized in similar and Births. In 2017, nurse midwives were recorded different ways across the settings:. as attending almost 50,000 births in the state, or somewhat more than 10 percent of the • Hospitals. The vast majority of births, whether 470,000 births in the state that year. Why nurse attended by physicians or nurse midwives, midwives attend a significantly smaller proportion occur at the hospital. In California, essentially of the births in California as compared to the 100 percent of physician-attended births and proportion of the specialty women’s health care 98 percent of nurse midwife-attended births— workforce they comprise is unclear. However, together totaling about 460,000 of the state’s one reason likely is that births attended by nurse births in 2017—occur at the hospital. Within midwives are not always recorded as such (for hospitals, labor and delivery care usually is example, they are recorded as having been provided within a standard obstetric unit or, attended by a physician). less commonly, within a birth center located Figure 1 Major Educational, Training, and Credential Differences Between Nurse Midwives and OB-GYNs Nurse Midwives OB-GYNs Education Requirements Bachelor’s degree Bachelor of Nursing or completion of Bachelor’s degree with medically similar coursework relevant coursework Master’s degree Master’s of Nurse-Midwifery — Doctoral degree — Doctor of Medicine or Doctor of Osteopathic Medicine Typical total years of post-secondary education 6 12a Clinical Training Experienceb Hours of general nursing/medical education clinical training 800 4,000 experience Hours of graduate-level nurse-midwifery or OB-GYN clinical 1,000 14,000c training experience Total hours of clinical training experience 1,800 18,000 Licensure and Certification Licensing requirement Licensed as registered nurses by Licensed as physicians by the the California Board of Registered California Board of Medicine or Nurses California Board of Osteopathic Medicine Specialty certification requirement Certified as nurse midwives by the Certified as OB-GYNs by the American Midwifery Certification American Board of Obstetrics Board and Gynecology a Includes years in residency. b LAO estimates. c A significant portion of these residency training hours relate to the diagnosis and treatment of conditions outside of the scope of practice of nurse midwives. For example, this training includes advanced procedures such as cesareans and hysterectomies and advanced treatments for illnesses such as for cancer. OB-GYN = obstetrician and gynecologist. 6 LEGISLATIVE ANALYST’S OFFICE analysis full gutter AN LAO REPORT on the same campus or in the same building California’s Rules Governing the as the hospital. Obstetric units typically are Practice of Nurse Midwives physician-led, whereas hospital-based birth This section describes the major practice rules centers typically are led by nurse midwives placed on nurse midwives. Figure 2 summarizes or collaborative nurse midwife and physician the major practice differences between nurse teams. Primary care and family planning midwives and OB-GYNs in terms of where they services, whether delivered by physicians or typically practice and how they can practice. nurse midwives, commonly occur outside of the hospital. Nurse Midwives May Only Practice Under the Supervision of a Physician. In California, nurse • Freestanding Birth Centers. Freestanding midwives may only practice—to their full scope of birth centers are outpatient facilities where practice—under the supervision of a physician. For women can give birth in a health care nurse midwives, a supervisor must be a physician setting other than a hospital. Freestanding with a current practice or training in obstetrics. birth centers typically are staffed by nurse State law does not further define the requirements midwives and licensed midwives and generally of physician supervision for nurse midwives, except are intended for expecting mothers who as specifically related to the furnishing (prescribing) prefer fewer medical interventions be used during delivery. Physicians generally do not attend births Figure 2 within this setting. Around Major Practice Differences Between Nurse Midwives and OB-GYNs 1,400 births occurred in freestanding birth centers in Nurse Midwives OB-GYNs 2017, or less than 1 percent Common Practice Settings of the state’s births that year. Hospital-based deliveries ü ü • Home Settings. Some Freestanding birth center deliveries ü women—somewhat more Home-birth deliveries ü than 2,000 women in 2017— Clinic-based primary care ü ü opt to deliver outside of Practice Restrictions and Authority a health care setting and Physician supervision required ü instead do so at home. Home Scope of practice limited in state law ü births are predominantly attended by licensed Practice Authority to: midwives (86 percent) or by Provide primary care and family planning services ü ü nurse midwives (12 percent). Deliver prenatal, postpartum, and newborn care ü ü Physicians attend the Furnish (prescribe) medications ü ü remaining 2 percent. Attend low-risk and normal childbirths ü ü • Women’s Health Clinics. Attend births experiencing complicationsa ü Women’s health clinics offer Deliver twins ü a range of primary care and Deliver with the use of medical instruments ü gynecological outpatient services tailored to women Perform cesarean sections ü and their reproductive health. Perform gynecological surgeries ü Births do not take place in Provide gynecological cancer treatment ü women’s health clinics. a When a low-risk birth experiences complications, nurse midwives are required by state law to immediately refer and transfer the birth to a physician’s care. OB-GYN = obstetrician and gynecologist. www.lao.ca.gov 7 analysis full gutter AN LAO REPORT of medication, the repair of minor lacerations, and State Scope-of-Practice Rules Limit Nurse the making of small cuts to prevent lacerations Midwives to Attending “Normal Childbirths.” (episiotomies). There is no state requirement Under California law, nurse midwives are authorized that nurse midwives practice within the same to be the exclusive attendant only for normal geographic vicinity as their physician supervisor. As childbirths. Childbirths are considered normal only such, the physical presence of a nurse midwife’s for women whose pregnancies are designated supervisor is not required under state law during as low risk, and are best illustrated by examples deliveries or other services provided by nurse of their exceptions. Accordingly, for example, midwives. high-risk pregnancies include the birthing of Nurse Midwives May Furnish Medications twins or significantly pre- or post-term deliveries. in Accordance With Standardized Procedures. Additionally, nurse midwives may not deliver Nurse midwives have the authority under state law children by mechanical means, such as with the to furnish medications. They must do so, however, use of forceps or a vacuum. in accordance with standardized procedures that Immediate Referral to a Physician Is Required are developed and approved in collaboration with When Childbirth Complications Arise. Nurse their supervising physicians. These standardized midwives are required to immediately refer women procedures establish which medications a nurse experiencing complications during childbirth to a midwife may furnish, under what circumstances physician. Examples of complications include labor they may do so, and how their competence and that is not progressing at a safe speed, or for which the standardized procedures will be periodically the use of medical instruments (such as forceps or reviewed. State law further limits the total number a vacuum) is necessary. Similarly, women in labor of medication-furnishing advanced practice nurses requiring an emergency cesarean section must that an individual physician may supervise at a be referred to a physician. Childbirths that feature given time. This limit is one supervising physician relatively minor lacerations, or for which minor to four advanced practice nurses who furnish surgical cuts are made to prevent lacerations, are medications. In addition, state law requires considered normal and are, therefore, within the that, for nurse midwives to furnish medications, scope of practice of nurse midwives. For hospital their supervising physician must be available via births, referral involves a simple handoff from the telephone at the time of a patient’s visit. attendant nurse midwife to an on-call physician. For freestanding birth center and home births, referral typically will entail transportation to a hospital. ANALYSIS In this section, we analyze the state’s women’s health care is impaired by restrictions physician-supervision requirement for nurse on nurse midwives’ independent practice, and midwives. Specifically, we assess whether this (3) whether such restrictions raise the costs of requirement is effective in ensuring and improving women’s health care. Third, we evaluate the the safety and quality of childbirth without effect of California’s physician-supervision law unreasonably impeding access or raising costs. from a California-specific perspective. Finally, we First, we lay out the evaluation framework we use present our assessment of how removal of the to analyze this (and potentially other) occupational state’s physician-supervision requirement for nurse restrictions. Second, we summarize national midwives could impact access to relatively safe, research findings on (1) the safety and quality of high-quality, and cost-effective women’s health care nurse-midwife services across various practice services. settings (including across different occupational licensing requirements), (2) whether access to 8 LEGISLATIVE ANALYST’S OFFICE analysis full gutter AN LAO REPORT EVALUATION FRAMEWORK feasible, occupational restrictions should be judged in comparison to other policies that could achieve This section describes the evaluation framework the same purpose. Figure 3 summarizes our that we utilize in this report to assess the benefits evaluation framework for assessing occupational and trade-offs of the physician-supervision restrictions in health care broadly. requirement for nurse midwives. Occupational Restrictions for Nurse Midwives Occupational Restrictions Can Be Should Allow and Facilitate Access to Safe, Appropriate Insofar as They Achieve a Public High-Quality, and Cost-Effective Care. As Purpose... Occupational restrictions—such as discussed in the background, California state law licensure, scope-of-practice regulations, and requires nurse midwives to practice under the supervision requirements—can be appropriate supervision of a physician and places certain other insofar as they achieve a public purpose without scope-of-practice restrictions on nurse midwives. imposing unreasonable trade-offs. In general, Consistent with our evaluation framework for occupational restrictions can be an appropriate occupational restrictions for health care services means to implement the broad public purpose of generally, we view the state’s restrictions on ensuring and improving the safety and/or quality of nurse-midwife practice as appropriate insofar a given service. In particular, such restrictions may as they allow and facilitate access to relatively be appropriate when (1) consumers would have safe, high-quality, and cost-effective care. Ease difficulty observing and/or predicting the safety of access—having sufficient numbers of available or quality of a given service and (2) there is risk health care providers throughout the state—should of serious and irrevocable harm when a service is be considered in conjunction with the effects on performed poorly. safety and quality. Figure 4 (see next page) defines …But There Are Trade-Offs to Consider. As the key terms of our framework. previously noted, occupational restrictions bring This Analysis Examines California’s trade-offs. Imposing an occupational restriction Physician-Supervision Requirement. Applying inherently involves erecting a barrier to entering an the evaluation framework outlined above, this occupation, and thereby prevents consumers from analysis specifically examines the effectiveness of obtaining a service from any provider they choose. California’s physician-supervision requirement for Doing so can impede competition among service nurse midwives by asking the following questions: providers and, as a result, potentially raise prices and reduce access to those services. Moreover, occupational restrictions can have the potential to impair the quality Figure 3 of services when they prevent LAO Evaluation Framework for Assessing competent but uncredentialed Occupational Restrictions in Health Care providers from entering a market to compete on the quality of their Occupational restrictions may be appropriate when: services. Given these trade-offs, ü Consumers would have difficulty observing and/or predicting the quality or safety of occupational restrictions should a given health care service. be employed by policymakers ü There is a risk of serious and irrevocable harm when a health care service is performed poorly. with scrutiny and care, and be reassessed as evidence arises Trade-offs to consider in establishing an occupational restriction: ü regarding impacts on safety, The impact on access to health care services. quality, access, and cost. When ü The impact on the cost of health care services. ü Potential to impair rather than improve the quality of health care services. LAO = Legislative Analyst’s Office. www.lao.ca.gov 9 analysis full gutter AN LAO REPORT • Does the Requirement Improve the Safety Figure 5 summarizes our evaluation framework and Quality of Maternal and Infant Health for assessing the state’s physician-supervision Care? As with other occupational restrictions, requirement for nurse midwives. the fundamental purpose of California’s physician-supervision requirement for nurse ASSESSMENT OF midwives is to ensure and improve the safety NATIONAL RESEARCH FINDINGS and quality of mothers’ and infants’ health care. To judge safety and quality, we examine This section provides our assessment of national the growing body of research on the question research on how occupational restrictions related of whether (1) care by a physician results in to nurse-midwife practice affect (1) the safety and superior maternal and infant health outcomes quality of women’s health care, (2) access to such compared to care by a nurse midwife and care, and (3) the cost-effectiveness of such care. (2) whether states with less strict occupational restrictions on nurse midwives experience State Laws Vary for Nurse Midwives worse health outcomes for mothers and Nurse Midwives’ Independence Varies. Nurse infants compared to states with stricter midwives are allowed to practice and are active in restrictions. all 50 states. However, state laws vary significantly • Does the Requirement Unreasonably regarding the degree to which they allow nurse Impede Access to Care? As previously noted, Figure 4 occupational restrictions can Defining the Terms of the LAO Evaluation Framework impede access to services as Applied to Nurse Midwives governed by the restrictions. In this analysis, we examine Access: Ability of individuals to successfully obtain pregnancy, labor whether California’s and delivery, and reproductive health care in a timely manner from an physician-supervision appropriate and preferred provider. requirement unreasonably Safety: Protection from risk and injury related to pregnancy, labor and delivery, and reproductive health. impedes access to women Quality: A summary measure combining (1) patient satisfaction with and infants’ health care pregnancy, labor and delivery, and reproductive health care and (2) the services. consistency of such care with clinical best practice guidelines. • Is the Requirement Cost-Effective: Effectiveness or value in terms of safety, quality, and Relatively Cost-Effective accessibility of health care in relation to the costs of such care. Compared to Alternative LAO = Legislative Analyst’s Office. Approaches to Ensuring Safety and Quality? Occupational restrictions Figure 5 are one of a variety of LAO Evaluation Framework for Assessing the State’s policy approaches for Physician-Supervision Requirement for Nurse Midwives ensuring and improving Requiring physician supervision of nurse midwives can be appropriate if theory and the safety and quality of a evidence show: given service. As such, we ü The safety and/or quality of health care provided by nurse midwives appears deficient evaluate whether California’s compared to that of physicians. physician-supervision ü The requirement improves safety and/or quality of women’s health care. requirement appears ü relatively cost-effective in The requirement does not unreasonably impede access to women’s health care. improving safety and quality ü The requirement appears relatively cost-effective compared to alternative approaches as compared to alternative to ensuring safety and quality. approaches. LAO = Legislative Analyst’s Office. 10 LEGISLATIVE ANALYST’S OFFICE analysis full gutter AN LAO REPORT midwives to practice independently. States with supervision or collaboration agreements and which high degrees of “independent practice” for nurse allow independent practice. midwives do not require physician supervision Care Provided by Nurse Midwives Is and generally impose fewer scope-of-practice restrictions on nurse midwives. Examples of such Comparable to Physician Care scope-of-practice restrictions include limitations on Hospital-Based Labor and Delivery Care by nurse midwives’ authority to furnish medication and Nurse Midwives Compares Favorably to Care to practice at a faraway geographic distance from Provided by Physicians. Academic researchers their supervising physician. have extensively explored how hospital-based About Half of States Require Physician labor and delivery care by nurse midwives for Oversight. California is among four states that women with low-risk pregnancies compares to require physician supervision of nurse midwives. such care by OB-GYNs and other physicians. (As Nineteen other states require nurse midwives previously noted, in California, 98 percent of nurse to maintain “collaboration agreements” with a midwife-attended births occur at the hospital.) physician. Collaboration-agreement requirements This body of research demonstrates that the care are broadly similar to physician-supervision provided by nurse midwives during labor and requirements. They generally entail written delivery in hospitals is comparable, or in some agreements between nurse midwives and their cases, potentially superior to the care provided by collaborating physicians that outline the parameters physicians. For example, infant mortality rates and under which a nurse midwife may practice. other infant outcomes are comparable for nurse The remaining 27 states allow nurse midwives midwives and physicians. Infants whose births are to practice independently, that is, without a attended by nurse midwives are no more likely physician-supervision or collaboration-agreement to require emergency or other heightened forms requirement. Figure 6 displays which states require of care than infants delivered by physicians, as Figure 6 California Among 23 States to Require Physician Oversight of Nurse Midwives States Requiring Supervision, Collaboration Agreements, or Allowing Independent Practice Physician supervision 4 States Physician collaboration agreements 19 States Independent practice 27 States www.lao.ca.gov 11 analysis full gutter AN LAO REPORT measured by low scores on the common Apgar assessment, the safety and quality of care assessment (a test done on newborns to assess provided at freestanding birth centers appears whether they are healthy). In addition, labor and roughly comparable to, if not slightly more deliveries attended by nurse midwives are less risky than, care in hospitals. At the very least, likely to be intervened in, as evidence by the given the varied findings in the studies we lower usage of episiotomies, forceps, vacuum reviewed, we find there is relatively greater extraction techniques, and cesarean sections. uncertainty related to the safety and quality of Such interventions, while critical in cases of care in freestanding birth centers compared to medical necessity, come with risks and therefore hospital settings. Importantly, the studies that are recommended to be employed only as needed. examine births in freestanding birth centers Figure 7 summarizes our assessment of academic do not necessarily examine which type of research findings as they pertain to the care provider attends the planned birth. Therefore, provided by nurse midwives and physicians, mostly the studies do not show the impact of the in hospital settings. provider type on safety and quality within this Greater Variation and Uncertainty in Safety setting. and Quality of Care by Nurse Midwives Outside • Home Birth Care. In our review, studies of the Hospital. As discussed above, the research on the safety and quality of planned home literature amply demonstrates the quality of labor births varied significantly in their results—with and delivery care provided by nurse midwives some showing better outcomes for hospital in hospital settings—by far the most common births and some showing better outcomes for setting. However, in our review of the research literature, we found Figure 7 less conclusive and more mixed Nurse-Midwife Care Is at Least Comparable to Care by evidence of the safety and quality Physicians for Women With Low-Risk Pregnancies of care in other settings where Better Outcomes Associated Evidence nurse midwives practice commonly. Selected Outcomesa With Nurse Midwives? Gradeb To a significant degree, this likely is due to there being less published Labor Process Outcomes Related to: research on care in these other Labor induction utilizationc Yes High settings. In the following bullets, Labor augmentation utilizationc Yes M oderate Overall length of labor and delivery No Differenced Suggestive we provide our assessment of the research on safety and quality in Birth Process Outcomes Related to: the major nonhospital settings in Cesarean section utilizationc Yes High Episiotomy utilizationc Yes High which nurse midwives practice. Forceps/vacuum extraction utilizationc Yes Moderate • Labor and Delivery Care Infant Health Outcomes Related to: in Freestanding Birth Apgar scores No Differenced High Centers. A number of studies Mortality rates No Differenced Suggestive compare labor and delivery Breastfeeding rate Yes Suggestive outcomes (in terms of safety Maternal Health Outcomes Related to: and quality) between hospital Perineal lacerations Yes Moderate births and freestanding Mortality rates No Differenced Suggestive birth centers, the latter of Postpartum hemorrhage No Differenced Suggestive a which often are staffed by While the table includes only selected outcomes, the findings generalize to many other outcomes studied in the literature, which generally shows nurse-midwife care to be at least comparable to care by a physician. We note that nurse midwives. Some of these studies primarily compare nurse-midwife and physician care in hospital settings. b these studies show superior Evidence grades range in robustness from “high” for findings supported by a broad range of studies, “moderate” for findings supported by fewer and/or less methodologically rigorous studies, and to “suggestive” for findings that would outcomes in freestanding benefit from confirmation from additional and methodologically varied studies. c birth centers while others Care guideline is to reduce when medically unnecessary. d Literature generally does not show consistent significant differences in outcomes between the two provider types. show the opposite. In our 12 LEGISLATIVE ANALYST’S OFFICE analysis full gutter AN LAO REPORT planned home births. In our assessment, on occupational restrictions on nurse midwives and balance, planned home births appear to come improved maternal and infant health outcomes. with some elevated risk compared to other Because these studies examine basic associations birth settings. Planned home births usually (while controlling for certain relevant differences are attended by midwives, with the majority among states, such as demographics and average in California being attended by licensed educational attainment), they do not establish midwives rather than nurse midwives. As with a firm, causal relationship showing whether or births in freestanding birth centers, the studies not occupational restrictions on nurse midwives that examine home births do not necessarily improve health outcomes. examine which type of provider attends the Occupational Restrictions on planned birth. Therefore, the studies do not show the impact of the provider type on safety Nurse Midwives Are Associated With and quality within this setting. Less Access to Their Services • Women’s Primary Care Services. We Researchers have examined whether states reviewed a small selection of studies that with fewer occupational restrictions on nurse specifically compares the safety and quality midwives have a proportionately higher number of of primary care provided by nurse midwives nurse midwives and therefore, greater access to versus physicians, including care before and nurse-midwife services for those desiring them. This after childbirth. As a whole, these studies do research finds that in states with fewer occupational not find major differences in the safety and restrictions on nurse midwives—including, but quality of care provided by nurse midwives not necessarily limited to, physician-supervision and physicians. That said, given the small or collaboration-agreement requirements— number of studies that we found that there are proportionately more nurse midwives evaluated this aspect of the care provided by practicing and more births are attended by nurse nurse midwives, we find there to be somewhat midwives. For example, one study of 12 million greater uncertainty around the comparability births nationwide showed that in states that do of physician and nurse-midwife care for not require physician supervision or collaboration women’s primary care services. agreements, the proportion of all births attended States With Less Stringent Restrictions on by nurse midwives is nearly 60 percent higher Nurse Midwives’ Independent Practice Do Not than states with such requirements. Similarly, Experience Worse Birth Outcomes. Several states with generally less stringent occupational research studies explore whether states with restrictions tend to have higher numbers of nurse less stringent occupational restrictions on nurse midwives on a per-population basis and higher midwives experience worse birth outcomes. One utilization of nurse-midwife services. We note study we reviewed specifically examines whether that since these studies are observational as physician-supervision or collaboration-agreement opposed to experimental in nature, whether fewer requirements are associated with improved birth occupational restrictions actually cause an increase outcomes. Other studies look at occupational in the number of practicing nurse midwives, or if restrictions broadly rather than strictly focusing on other factors explain the identified relationship, is whether a state allows nurse midwives to practice uncertain. without physician supervision or collaboration Nurse Midwives Likely Provide agreements. Nevertheless, for these latter Relatively Cost-Effective Care studies, physician-supervision requirements are an important component used by researchers Several studies directly compare the costs of to ascertain the extent by which occupational care provided by nurse midwives and OB-GYNs. restrictions affect nurse midwives’ ability to practice There also are strong practical reasons to independently. This research generally finds no expect that care by nurse midwives is less costly association between relatively more stringent www.lao.ca.gov 13 analysis full gutter AN LAO REPORT compared to OB-GYNs. This section lays out training costs likely are compensated within the the main reasons. We note that, provided the health care system through higher incomes for effectiveness (safety and quality) of care remains physicians, ultimately leading to higher women’s constant or improves, a reduction in costs health care costs overall than they would otherwise necessarily increases its cost-effectiveness. be. Other key factors, such as OB-GYNs’ Nurse Midwives Employ Fewer Costly Labor ability to provide care in complex cases—which and Delivery Interventions Than Physicians. derives from their more extensive training—also Among only low-risk pregnancies, births attended likely contribute to their higher incomes. (While by nurse midwives tend to have lower rates of OB-GYNs’ extra competencies are critical in intervention in the labor and delivery process complex cases of pregnancy, labor, and delivery, compared to births attended by physicians. As they are not necessarily needed in the case of shown in Figure 7, labor and delivery care by normal childbirths—the type of births which nurse nurse midwives is associated with lower utilization midwives are authorized to solely attend.) In the of labor augmentation methods, labor induction long run, nurse midwives’ lower training costs and methods, episiotomies, vacuum/forceps extraction, earnings likely translate into lower health care costs and cesarean sections. Such interventions, when for the system as a whole. not medically necessary, can raise the cost of labor and delivery, either because there is an extra EVALUATING THE IMPACT charge for the specific intervention or because the OF CALIFORNIA’S intervention—particularly in the case of cesareans— PHYSICIAN-SUPERVISION results in a longer length of stay at the hospital. For REQUIREMENT example, because the intervention itself is costly and is associated with longer lengths of stay at the The previous section largely summarized hospital, cesarean deliveries are generally between national research findings on the relative safety, 60 percent and 90 percent more costly than vaginal quality, and cost-effectiveness of care by nurse deliveries. Overall, given the evidence that nurse midwives, as well as how access to nurse-midwife midwives tend to minimize the unnecessary use services varies based on differences among of labor and delivery interventions, utilizing nurse states in their occupational restrictions. This midwives to a greater extent could increase the section turns to California, informed by the cost-effectiveness of labor and delivery care. national research findings. First, we discuss Nurse Midwives’ Salaries Are Generally the likely impacts on safety and quality of the Lower Than OB-GYNs’. In California, average state’s physician-supervision requirement for annual salaries for nurse midwives are $135,000, nurse midwives, given the specifics of the whereas OB-GYNs earn $225,000 annually. Thus, state’s requirement and how it is implemented in nurse midwives earn about 60 percent of what practice. Second, we summarize several other OB-GYNs earn. One likely reason that nurse quality-assurance mechanisms applicable to the midwives’ salaries are lower is the significantly provision of women’s health care that are widely lower cost of their training. As shown in Figure 1, utilized or present in the health care sector. Third, to practice, a nurse midwife typically must we discuss the theoretical and practical reasons attend six years of post-secondary education for how the state’s requirement could impede and training. OB-GYNs, on the other hand, must access to and raise costs for nurse-midwife attend 12 years of post-secondary education and services. Fourth, we provide empirical evidence training, including residency. This added time and that access to nurse-midwife services appears the associated financial commitment come with limited in California. Lastly, we bring together significant costs for OB-GYNs, often in the form these components to discuss the potential impact of student loans. Average physician student loan of the state’s requirement on the safety, quality, debt can be as much as four times as high as the accessibility, and costs of women’s health care average amount for nurse midwives. These high services in California. 14 LEGISLATIVE ANALYST’S OFFICE analysis full gutter AN LAO REPORT California’s Requirement Unlikely clinical chart reviews—with their nurse-midwife to Have Significant Impact on supervisees. Accordingly, one of the major mechanisms by which a physician-supervision Improving Safety and Quality requirement could improve safety and quality is not Physician Supervision Is Not Well-Defined… a provision within state law. California state law establishes few parameters on Requirement Unlikely to Significantly what physician supervision of nurse midwives must Improve Safety and Quality. Due to the flexibility entail. Instead, many of the terms of supervision of California’s physician-supervision requirement, are allowed to be determined by supervising described above, we find that California’s physicians, their nurse-midwife supervisees, and requirement is unlikely to be any more effective the health systems in which they work. than other states’ similar requirements at improving …Resulting in Significant Variation in How safety and quality. Given the lack of differences at Supervision Is Carried Out in Practice… the national level for safety and quality between Since the state’s requirement is not well defined, states with and without physician oversight physician supervision can vary widely in how it is requirements, California’s supervision requirement carried out in practice. Some physician supervisors specifically likely does not significantly improve might regularly interact with their nurse-midwife safety and quality for maternal and infant health. supervisees, while others might collaborate in Moreover, as described in the next section, we the initial establishment of their nurse-midwife identify a number of other quality-assurance supervisees’ scope of practice and standardized mechanisms that are widely utilized in the state’s procedures and have limited subsequent health care system that likely play an important role involvement. In addition, health systems might in ensuring the safety and quality of health care interpret the responsibilities and parameters services in the state. associated with the state’s physician-supervision Role of Other requirement differently. For example, we understand that some hospitals require physicians to cosign Quality-Assurance Mechanisms all inpatient admission orders by nurse midwives, The fundamental purpose of the state’s whereas other hospitals grant nurse midwives full physician-supervision requirement for nurse authority to admit patients. Along similar lines, midwives is to ensure safe and high-quality care. we understand that some health systems require Previously, we discussed how licensure and physicians to cosign medication orders, while certification commonly is used to achieve this others do not. (We note that state law is more purpose, including in the case of nurse midwives. prescriptive regarding physician supervision of Other quality-assurance mechanisms and practices, nurse midwives who furnish medication.) in addition to the licensure and certification of …Which Limits the Requirement’s Potential professionals, are broadly utilized for ensuring Effectiveness. We recognize that the lack of high-quality and safe health care. Below are several prescriptiveness in state law likely has efficiency such mechanisms and practices: benefits in that it allows flexibility in how the physician-supervision requirement is implemented • Facility-Specific Regulation. In addition to based on the varying competencies of individual occupational restrictions, the state regulates nurse midwives. This allows, for example, varied health care facilities with the intent of ensuring levels of direct supervision for lesser and more high-quality and safe care. Such regulations experienced nurse midwives. However, importantly, can involve licensure, or a certificate that the lack of prescriptiveness also limits the law’s allows the performance of a specific set of potential effectiveness. For example, the state’s services only within licensed facilities. In physician-supervision requirement places no other cases, the state requires facilities to be responsibilities on supervising physicians to perform accredited—which can be similar to licensure quality-assurance activities—such as periodic but is carried out by a nongovernmental entity. www.lao.ca.gov 15 analysis full gutter AN LAO REPORT Such rules and regulations—whether by a provides an incentive for providers to reduce licensing government agency or an accrediting their risk by ensuring safe and high-quality body—typically mandate the maintenance of a care. safe and clean facility environment, standards • Reputational and Financial Interests Among for hiring qualified personnel, systems for Providers, Facilities, and Payers. Providers, managing confidential health information, facilities (such as hospitals), and payers of and processes for ensuring performance health care services (health plans and insurers) improvement. Hospitals and freestanding have an interest in showing their patients and birth centers currently are subject to licensing customers that the health care they provide requirements within state law. (often indirectly for health plans and insurers) • Quality-Improvement Processes. Health is safe and high quality. Accordingly, hospitals systems and provider groups regularly regularly market themselves as being highly employ formalized quality-improvement rated along safety and quality dimensions, processes to assure and improve the safety while health plans and insurers often compete and quality of their practices. At a minimum, to provide access to highly rated hospitals such processes involve evaluation of past and other providers within their networks. performance, comparing it to benchmarks Conversely, hospitals with poor safety and or goals, and strategizing methods of quality records periodically are closed, improvement. For health care providers, for change management, or are cut from health example, quality-improvement processes plans’ and insurers’ provider networks. Thus, regularly involve the review of patients’ clinical protection of the reputational and associated charts to assess whether the providers’ financial interests of health facilities and treatment plans met accepted standards of payers work towards ensuring and improving care. Quality-improvement processes likely safety and quality. Given these incentives, play a major role in assuring and improving health systems voluntarily employ a wide the safety and quality of health care broadly, variety of quality-assurance practices, some of including services related to women’s health which we have described earlier. and childbirth. • Medical Malpractice. Medical malpractice How California’s is an area of law whereby patients who Physician-Supervision Requirement believe they have received substandard Could Impede Access and health care may sue their providers for Raise Costs damages. The prospect of receiving a medical malpractice claim is intended to deter health There are theoretical and practical reasons to care providers from providing negligent or suggest that the state’s physician-supervision otherwise substandard care. In anticipation requirement impedes nurse midwives’ ability to of potential medical malpractice claims, both establish independent practices, as discussed nurse midwives and physicians typically further below. Through such practices, nurse maintain medical malpractice insurance, midwives can build their own patient bases, with which covers the policy holder in the face whom they can perform an array of women’s health of a medical malpractice lawsuit. Medical primary care services, and also assist through malpractice insurance carriers generally labor and delivery. Primary care services take base the rates they charge for coverage on place at primary care clinics or freestanding birth their estimation of the risks inherent in a centers run by the nurse midwives. Labor and given provider or provider group’s practice. delivery is attended at nearby hospitals—where Accordingly, they play a role in ensuring nurse midwives have admitting privileges—or quality by charging premium amounts based at freestanding birth centers. As with all nurse on the riskiness of providers’ practices. This midwives, nurse midwives wishing to establish such 16 LEGISLATIVE ANALYST’S OFFICE analysis full gutter AN LAO REPORT independent practices must first obtain a physician could go beyond the costs and risks associated supervisor under state law. As described below, with supervision to reflect a payment being made physicians can be hesitant to provide statutorily to allow competitors (nurse midwives) to enter the required supervision, or can require compensation market and establish independent practices. (Such to provide such supervision. payments would not be in the public interest insofar To Practice, Nurse Midwives Must Obtain as they only compensate physicians for authorizing Consent From a Potential “Competitor.” There the establishment of independent practices with are a number of reasons why a physician may which they would have to compete.) choose not to supervise a nurse midwife. For one, Such Impediments to Nurse Midwives’ Ability a physician may not wish to perform the added to Establish Independent Practices Could supervisory activities that they believe would Impede Access. The state’s physician-supervision fulfill their duties as a supervisor. Additionally, requirement could impede access in three ways. a supervising physician may be concerned First, and most directly, nurse midwives unable to that they could be held liable in a successful obtain statutorily required physician supervision medical malpractice suit against a nurse-midwife may not establish independent practices through supervisee. Alternatively, a physician may not which patients could obtain care. Second, for nurse wish to sanction—through fulfilling the state’s midwives who obtain a supervisor, the payments supervision requirement—the establishment made in exchange for physician supervision likely of an independent practice with whom they are passed on to patients and payers as higher would compete for patients. The Federal costs. Patients might obtain fewer services to Trade Commission, in its 2014 report, Policy the extent they or their payers have to pay these Perspectives: Competition and the Regulation of higher costs. Third, the ability of nurse midwives Advanced Practice Nurses, voiced this concern, to compete with other providers on cost is stating that “physician-supervision requirements impeded by the higher costs associated with these establish physicians as gatekeepers who control payments. Thus, the state’s physician-supervision [advanced practice nurses’] independent access requirement might limit the establishment of to the market.” As is the case in markets generally, additional nurse midwife-run independent practices granting a competitor the authority to prevent the by making them less economically viable. Not establishment of rival firms undermines the ability only could these impediments limit access to of markets and competition to deliver high-quality nurse-midwife services, they also could limit access goods and services at reasonable prices. For this to women’s health care more broadly, particularly in reason, the physician-supervision requirement for rural areas where services from physicians may not nurse midwives raises anti-competitive concerns. be readily available. Physicians Sometimes Ask for Payment in Evidence for Limited Access in Return for Supervision. We understand that California physicians sometimes ask for payment in return for agreeing to supervise nurse midwives (particularly In the previous section, we discussed the in the case of nurse midwives who practice theoretical and practical reasons for how independently from major hospital systems and/ California’s physician-supervision requirement or medical groups). Such payments can reimburse could limit access to nurse-midwife services—and physicians for the time spent on supervision potentially women’s health care services more activities and can also serve to compensate broadly. In this section, we describe empirical physicians for any potential risk incurred should evidence specific to California that suggests they be named in a medical malpractice suit nurse-midwife services might be undersupplied against a nurse-midwife supervisee. In these cases, relative to the demand for their services, thereby the payments would compensate physicians for suggesting access to their services could be the legitimate costs and risks associated with limited. The first two pieces of evidence relate supervision. In theory, the payment to physicians to potential limits in access to labor and delivery www.lao.ca.gov 17 analysis full gutter AN LAO REPORT care by nurse midwives. The second two pieces their insurance did not cover midwife services, a of evidence show that (1) nurse-midwife services midwife was not available, a different provider type overall appear to be in high demand and (2) access was assigned to them, and the belief that midwives to women’s health care services overall could be could not practice in hospitals. limited in the more rural and inland areas of the Robust Growth in Earnings Suggests state. Demand for Nurse-Midwife Services May Nurse-Midwife Care Potentially Is Appropriate Exceed Supply. Robust growth in earnings over for More Women Than Are Currently Served time for an occupation can provide evidence that in the State. Research suggests that between demand for the services provided by members 50 percent and 75 percent of births are normal of the occupation exceeds supply. Bureau of and therefore eligible for nurse-midwife services. Labor Statistics data show that between 2013 However, nurse midwives currently likely only and 2018 nurse midwives’ average salaries attend, at most, 20 percent of the births for which increased at a faster rate than those for both they could be an appropriate provider. OB-GYNs and health care practitioners generally Survey Data Indicate a Higher Proportion of in California. Figure 9 shows these trends. This Women Want Than Receive Midwife Services. provides further evidence suggesting that demand The Listening to Mothers in California survey for nurse midwives exceeds their supply. showed that 17 percent of survey participants Geographic Disparities in Access to (mothers who gave birth in California in 2016) would OB-GYNs. As with other physicians in California, definitely want to utilize a midwife’s services. OB-GYNs tend to practice disproportionately in (The survey question does not distinguish between nurse Figure 8 midwives and licensed midwives.) Use of Midwife Services: An additional 37 percent of survey Comparing Prior Use to Future Preferences participants said that they would consider utilizing a midwife’s 60% services, bringing the total percent of women who would at least consider a midwife’s 50 services to 54 percent. In contrast, 9 percent of participants reported having previously utilized 40 a midwife’s service. Figure 8 Would Consider summarizes these survey findings. Using a Midwife The survey found, however, 30 that among mothers who would have preferred to use a midwife, 25 percent reported experiencing health problems necessitating 20 referral to a physician rather than a midwife. A significant portion of the remaining 75 percent cited 10 Would Want reasons related to access— a Midwife Used a Midwife defined as the ability to have an appropriate and preferred provider—for why they did not Note: Survey does not distinguish between nurse midwives and licensed midwives. use midwife services. Such Source: Listening to Mothers in California, 2018. reasons included the belief that 18 LEGISLATIVE ANALYST’S OFFICE analysis full gutter AN LAO REPORT certain regions of the state. For Figure 9 example, as shown in Figure 10 Earnings for Nurse Midwives Have (see next page), the Greater Bay Grown Faster Than Other Related Occupations Area has nearly three times as Cumulative Percent Change From 2013 to 2018 many OB-GYNs per 1,000 births than the Inland Empire—and 20% over 50 percent more than the statewide average. The San 16 Joaquin Valley and northern and Sierra regions of the state also have significantly fewer OB-GYNs 12 per 1,000 births than the more urban and coastal regions of the 8 state. This suggests that—when only counting OB-GYNs—access to women’s health care services 4 might be limited in certain areas of the state. Later in the report, we describe how nurse midwives Obstetricians and All Health Occupations Nurse Midwives could serve to fill the gaps in Gynecologists access in the more rural and inland regions of the state. POSSIBLE EFFECTS OF Requirement Likely Is a REMOVING CALIFORNIA’S Factor Contributing to Limited Access to Nurse-Midwife Services PHYSICIAN-SUPERVISION REQUIREMENT Bringing together our various findings discussed previously, in our assessment, California’s Enacting policies to increase access to physician-supervision requirement likely is a factor nurse-midwife services could increase access to contributing to limited access to nurse-midwife women’s health care services, generally maintain services in the state, and potentially to women’s safety and quality, and lower costs. Removing health care services overall. First, as previously California’s physician-supervision requirement discussed, national research shows that states reflects one promising avenue to do so. In this without occupational restrictions such as physician section, we assess the potential impact of removing oversight have proportionately more nurse midwives the state’s physician-supervision requirement and more births attended by nurse midwives. from state law on the safety and quality, access, Second, physician control over nurse-midwife and cost-effectiveness of women’s health care, access to the market through supervision including labor and delivery care. requirements provides a sound theoretical and practical mechanism by which such requirements Impact on Safety and Quality Could could limit access to nurse-midwife services, and Be Positive, Particularly in Hospital women’s health care services overall. Third, we find Settings empirical evidence that access to nurse-midwife services—and potentially women’s health care Potentially Positive Impact on Safety and services overall, at least in certain regions of the Quality in Hospital Settings, the Most Common state—is limited. Setting for Childbirth. In our assessment, removing the state’s physician-supervision requirement for nurse midwives could improve www.lao.ca.gov 19 analysis full gutter AN LAO REPORT the safety and quality of labor and delivery care in • Labor and Delivery Care. On the one hand, hospital settings, provided the removal leads to independent practice for nurse midwives greater utilization of nurse-midwife services in these may lead to greater utilization of labor and settings. As noted earlier, for low-risk births, nurse delivery care outside of the hospital setting midwives utilize fewer interventions, which can in freestanding birth centers and homes, improve safety and quality. where there is greater uncertainty related On Balance, Uncertain but Likely Limited to the safety and quality of care. While Impact on Safety and Quality Outside of this development would be positive from a Hospital Settings. There is greater uncertainty patient-choice perspective, it could come regarding the impact on safety and quality that with added risks for mothers and their removing the requirement would have on care infants relative to the care that otherwise provided by nurse midwives outside of the would have been provided in a hospital hospital—including labor and delivery care in setting. On the other hand, removing the nonhospital settings and women’s primary care. physician-supervision requirement could increase the safety and quality of care for Figure 10 Nurse Midwives Reduce Geographic Disparities in the Practice Locations of Women's Health Care Providersa Regional Providers Per 1,000 Births 2 4 6 8 10 12 14 Greater Bay Area Orange Sacramento Los Angeles Central Coast San Diego OB-GYNs Nurse Midwives Northern and Sierra San Joaquin Valley Inland Empire California Average California Average OB-GYNs Women's Health Care Providers a Here defined as OB-GYNs and nurse midwives. Data on licensed midwives was not available for inclusion. OB-GYN = obstetrician and gynecologist. Source: LAO Estimates using data from the California Health Care Foundation. 20 LEGISLATIVE ANALYST’S OFFICE analysis full gutter AN LAO REPORT women who otherwise would still have elected midwives, the majority of whom likely practice to deliver outside of the hospital. Removing in hospital settings. By removing California’s the physician-supervision requirement for physician-supervision requirement, more hospitals nurse midwives may encourage more nurse might grant broader admitting privileges to nurse midwives to attend home births, and thereby midwives, improving their employment prospects increase the average training and credential and making the profession more attractive to levels of attendants of home births. individuals deciding among careers. Rural hospitals, • Primary Health Care. A number of studies where we understand nurse midwives have greater indicate that the safety and quality of pre- and challenges finding physician-supervisors, would postnatal care are comparable regardless no longer face this barrier to employing nurse of whether the provider is a nurse midwife midwives. or a physician. However, we found relatively Removing Requirement Could Encourage few studies on the safety and quality of the Establishment of Independent Clinics nurse midwife-delivered primary care and Freestanding Birth Centers. Removing services not directly related to pregnancy the physician-supervision requirement for nurse and childbirth. Accordingly, the safety and midwives would remove a barrier—namely, quality of primary care services delivered by obtaining a physician’s consent—that currently nurse midwives is somewhat uncertain. That impedes nurse midwives’ ability to establish said, studies do show that the safety and women’s health clinics or freestanding birth centers, quality of primary care delivered by nurse as well as their ability to attend home births. As practitioners is comparable to physicians. such, removing this requirement could encourage Since (1) nurse-midwife education and training greater access to services in these settings, and on primary care services is comparable to that in doing so give expectant mothers more options of nurse practitioners and (2) about half of as alternatives to delivering in a hospital setting. California’s nurse midwives also are certified Previously, we discussed the potential safety and nurse practitioners, we find it likely that the quality impacts of such developments. safety and quality of such care would be Potentially Further Address Geographic roughly comparable for nurse midwives and Disparities in Access to Women’s Health physicians. Services. In California, OB-GYNs tend to practice disproportionately in certain regions of the state. On balance, we find that removing the Figure 10 shows that the Greater Bay Area, Orange physician-supervision requirement would have a County, the Sacramento region, and Los Angeles limited but somewhat uncertain impact on safety have more practicing OB-GYNs per 1,000 births and quality outside of hospital settings. than the statewide average. The remaining five Potential to Improve Access regions of the state have fewer practicing OB-GYNs per 1,000 births. As Figure 10 also shows, nurse Potentially Positive Impact on Access to midwives fill the gaps in women’s health care Nurse-Midwife Services in Hospital Settings. As in three of the five regions with relatively few previously discussed, survey data indicate more OB-GYNs: the Central Coast, San Diego, and women are eligible for and desire midwife services the northern and Sierra counties. Thus, while than currently receive them in the state. Removing there are five regions in the state with relatively California’s physician-supervision requirement limited access to women’s health care services could potentially facilitate more low-risk births when only counting OB-GYNs, just three regions being attended by nurse midwives. As previously of the state have relatively limited access (by discussed, states with fewer occupational this measure) once nurse midwives are counted restrictions on nurse midwives—including as providers. This shows that nurse midwives, physician-supervision and collaboration-agreement as a profession, have the potential to fill gaps in requirements—tend to have more nurse coverage in the areas of the state where relatively www.lao.ca.gov 21 analysis full gutter AN LAO REPORT few OB-GYNs practice. Removing the state’s would not be fully offset by other added costs, physician-supervision requirement is a means by such as those associated with other forms which the state could increase the number of nurse of increased health system oversight and midwives and—particularly given the constraints professional collaboration related to the care on rural hospitals previously discussed—address provided by nurse midwives. geographic disparities in access to women’s health care services. Specifying Responsibilities of Physician Oversight Has Drawbacks Likely Improve Cost-Effectiveness While the Lack of Definition of By reducing costs and potentially increasing Responsibilities of Physician Supervision access to nurse-midwife services—without Does Likely Impede the Law’s Effectiveness… significantly reducing safety or quality—removing Previously, we discussed why the lack of definition the state’s physician-supervision requirement has in the state’s physician-supervision requirement the potential to improve the cost-effectiveness of makes it unlikely that the requirement is effective women’s health care services. We expect costs to in significantly improving the safety and quality of be lower due to the following factors: maternal and infant health care. Therefore, one • Care Delivered by Less Costly Providers. way safety and quality might be improved would In California, nurse midwives earn about be to add definition and parameters to the state’s 60 percent of what OB-GYNs earn. In part, physician-supervision requirement. For example, this likely is due to the lower costs of training some states set maximum geographic distances a nurse midwife compared to an OB-GYN, as from which a physician can supervise a nurse well as different demands for their respective midwife. As another example, some states mandate skill sets. Accordingly, by increasing the periodic reviews of the nurse midwives’ clinical relative amount of care appropriately delivered chart by their physician supervisors. by nurse midwives, the state’s health system …Adding Definition and Parameters to could achieve savings. Physician Supervision Does Not Reflect the • Reduce the Use of Costly Labor and Best Approach. Further defining the state’s Delivery Interventions. National research physician-supervision requirement would not shows that nurse midwives tend to employ address the current competition issue—specifically, fewer costly labor and delivery interventions— granting potential competitors (physicians) the such as episiotomies and cesareans—than power to control nurse midwives’ access to the OB-GYNs. By increasing the proportion of market. As noted earlier, we believe this issue might births attended by nurse midwives, fewer costly be limiting access to nurse-midwife services in interventions might be utilized in the state, the state, and potentially to women’s health care thereby reducing labor and delivery costs. services more broadly. Moreover, this approach • Removal of the Costs Associated With would make the tasks associated with supervision Physician Supervision. Physician supervision more burdensome, potentially making supervision imposes costs on the health system in a less attractive to physicians, and thereby further number of ways, three being (1) the payments impeding nurse midwives’ ability to practice. made by nurse midwives to physicians in Safety and Quality Can Be Promoted Outside exchange for supervision, (2) the absence of the Physician-Supervision Framework. As of greater competition among providers previously discussed, physician-supervision of due to the anti-competitive nature of the nurse midwives is just one of a variety of policies physician-supervision requirement, and (3) any and procedures currently in place with the intention medical malpractice liability physicians bear of ensuring and improving the safety and quality as supervisors. By removing the requirement, of women’s health care. These policies and these costs would be eliminated and likely procedures—such as chart reviews, standardized 22 LEGISLATIVE ANALYST’S OFFICE analysis full gutter AN LAO REPORT procedures, and facility licensing or accreditation— providers. Accordingly, in the absence of a could be maintained and potentially improved upon physician-supervision requirement that applies in the absence of physician supervision of nurse to all nurse midwives, the Legislature could midwives. In our view, they are likely to be more consider adding statutory requirements that cost-effective than physician supervision since nurse midwives maintain appropriate referral they do not lead to similarly direct anti-competitive and consultative relationships with physicians effects as does physician supervision. and potentially other providers (such as other nurse midwives). Alternative Requirements Could • Practice as Part of a Larger Health Ensure Safety and Quality System. As discussed earlier in this report, health systems have an interest in In the absence of a physician-supervision ensuring that their providers deliver safe and requirement for nurse midwives, the Legislature high-quality care. As a result, they typically might want to consider alternative requirements for have quality-assurance and improvement nurse midwives that could serve the same intent practices in place—including practices of ensuring the safety and quality of their services. relating to the hiring and contracting of These alternative safety- and quality-assurance health care providers—to ensure safety and requirements would be in addition to those that quality. To maintain the safety and quality of are currently imposed as conditions of licensure nurse-midwife services in the absence of a and certification to practice as a nurse midwife. physician-supervision requirement, the state In our assessment, these alternative requirements could remove the requirement only for those could be more cost-effective than the state’s nurse midwives who practice as part of a physician-supervision requirement. larger health system—a category that could Legislative Approaches for Ensuring Safety include hospitals, medical groups, provider and Quality. At least some of these alternative associations, and health plans. Under this requirements could—in effect—be established model, for example, nurse midwives would statutorily in one of two main ways. First, alongside continue to perform certain duties, such removing the physician-supervision requirement, as furnishing drugs, in accordance with the Legislature could add one or more of the standardized procedures, which would be following requirements listed below as conditions of developed and approved in collaboration with licensure to practice as a nurse midwife. Second, the health systems in which they work. the Legislature could maintain a supervision • Maintain Medical Malpractice Insurance. requirement for nurse midwives, but establish Through their willingness to insure providers exceptions for those who meet one or more of the and charge differential rates based on requirements listed below. The potential alternative the riskiness of a given practice, medical requirements include the following: malpractice insurance carriers play a role • Maintain Referral and Consultative in ensuring safety and quality in the health Relationships With Physicians and care system. To ensure safety and quality Potentially Other Providers. Given nurse on the part of nurse midwives, absent midwives’ scope-of-practice limitations, physician supervision, the state could require which authorize them to attend only normal nurse midwives to maintain medical liability childbirths, nurse midwives must maintain insurance. This would ensure that only nurse relationships with physicians in order to midwives whose practices are below a certain refer women with abnormal conditions. In threshold of risk, as judged by medical liability addition, health care providers generally insurance carriers, are able to practice. benefit through consultation with other • Meet Minimum Clinical Experience providers—for example, by reviewing clinical Standards. In order to ensure the safety charts and challenging cases with external and quality of services provided by nurse www.lao.ca.gov 23 analysis full gutter AN LAO REPORT practitioners, a number of states require justify independent practice for newly trained nurse practitioners to have practiced a nurse midwives, the state could mandate minimum number of hours before granting that they gain additional clinical experience them authority to practice without physician before practicing without the supervision of oversight (supervision or collaboration a physician (or, potentially, another nurse agreements). A similar approach could be midwife). As a clinical experience standard, adopted to ensure the safety and quality the Legislature could consider attendance of of nurse-midwife services in California. If a minimum number of births or a minimum the training that nurse midwives receive number of clinical hours completed. with their education is judged insufficient to RECOMMENDATIONS The state’s physician-supervision requirement for • Consider Eliminating Supervision nurse midwives is intended to improve the safety Requirement for Nurse Midwives, Add and quality of women’s health care. Following Other Safeguards. Given the above our review of academic literature on the safety findings, we recommend that the Legislature and quality of care by nurse midwives, however, consider eliminating the requirement that we do not find sufficient evidence to justify this nurse midwives practice under physician occupational restriction for two reasons. First, we supervision and adding alternative statutory do not find evidence that the safety and quality of requirements to ensure the safety and quality maternal and infant health care by nurse midwives of nurse-midwife services. is inferior to that of physicians. Second, states with • Consider New Safety and Quality physician-supervision or very similar requirements Requirements in the Absence of Physician do not have superior maternal and infant health Supervision of Nurse Midwives. The outcomes. Consequently, the supervision Legislature could consider options for requirement for nurse midwives does not appear to ensuring and improving the safety and quality positively affect safety and quality. of nurse-midwife services in the absence of We also find that the state’s physician supervision. The Legislature could physician-supervision requirement for nurse consider adding statutory requirements, either midwives likely brings trade-offs by reducing access as conditions for nurse midwives to practice to nurse-midwife services, and potentially women’s under their license or as conditions to practice health care services more broadly, and making without supervision. Rather than allowing such services relatively more costly. Since, in our only physicians to serve as supervisors, assessment, the physician-supervision requirement the Legislature could consider authorizing likely does not significantly improve the safety and nurse midwives who meet the broadest set quality of care, retaining the physician-supervision of requirements to serve as supervisors for requirement brings trade-offs without producing any nurse midwives who do not meet all the significant, tangible benefits. Furthermore, we find requirements. New requirements for the that certain other quality-assurance mechanisms Legislature to consider include: could better ensure and improve safety and quality » Maintenance of Referral and Consultative without introducing trade-offs as significant as the Relationships With Physicians and state’s current physician-supervision requirement. Potentially Other Providers. Consider Accordingly, we recommend that the Legislature: requiring nurse midwives to maintain appropriate referral and consultative 24 LEGISLATIVE ANALYST’S OFFICE analysis full gutter AN LAO REPORT relationships with physicians and potentially midwives who practice in licensed health other providers (such as other nurse facilities. midwives). » Maintain Medical Malpractice Insurance. » Practice as a Part of a Health System. Consider requiring nurse midwives to Consider limiting the elimination of a maintain medical liability insurance. supervision requirement to nurse midwives » Meet Minimal Clinical Experience who practice as part of a larger health Standard. Consider requiring nurse system. midwives to meet a minimum clinical » Practice in a Licensed or Accredited experience standard as a condition of Facility. Consider limiting the elimination practicing without supervision. of a supervision requirement to nurse CONCLUSION The purpose of California’s physician-supervision raising women’s health care costs. We recommend requirement for nurse midwives is intended to that the Legislature consider removing the state’s ensure the safety and quality of women’s health physician-supervision requirement, while adding care. Drawing on national research—which, among other safeguards to ensure safety and quality. Such other things, does not find significant differences safeguards could include, for example, requiring in the quality of care between states that do and nurse midwives to maintain appropriate referral do not have this requirement—we find that this and consultative relationships with physicians and requirement is unlikely to achieve this purpose. requiring that they maintain medical malpractice Moreover, we find that the requirement could limit insurance. access to nurse-midwife services, and potentially women’s health care services overall, while also www.lao.ca.gov 25 analysis full gutter AN LAO REPORT 26 LEGISLATIVE ANALYST’S OFFICE analysis full gutter AN LAO REPORT SELECTED REFERENCES Altman, Molly R., Sean M. Murphy, Cynthia E. Fitzgerald, H. Frank Andersen, and Kenn B. Daratha. 2017. “The Cost of Nurse-Midwifery Care: Use of Interventions, Resources, and Associated Costs in the Hospital Setting.” Women’s Health Issues 27 (4): 434-40. https://doi.org/10.1016/j.whi.2017.01.002. Attanasio, Laura B., Fernando Alarid-Escudero, and Katy B. Kozhimannil. 2019. “Midwife-led Care and Obstetrician-led Care for Low-risk Pregnancies: A Cost Comparison.” Birth, November. https://doi. org/10.1111/birt.12464. Blanchette, H. 1995. “Comparison of Obstetric Outcome of a Primary-Care Access Clinic Staffed by Certified Nurse-Midwives and a Private Practice Group of Obstetricians in the Same Community.” American Journal of Obstetrics and Gynecology 172 (6): 1864-68; discussion 1868-71. https://doi.org/10.1016/0002-9378(95)91424-2. Chambliss, L R, C Daly, A L Medearis, M Ames, M Kayne, and R Paul. 1992. “The Role of Selection Bias in Comparing Cesarean Birth Rates between Physician and Midwifery Management.” Obstetrics and Gynecology 80 (2): 161-65. https://www.ncbi.nlm.nih.gov/pubmed/1635724. Cross-Barnet, Caitlin, Ian Hill, Lisa Dubay, Brigette Courtot, Sarah Benatar, Bowen Garrett, Fred Blavin, et al. 2018. “Health Management Associates ~AIR Strong Start for Mothers and Newborns Evaluation: Year 5 Project Synthesis Volume 1: Cross-Cutting Findings Prepared For.” https://downloads.cms.gov/files/cmmi/strongstart-prenatal-finalevalrpt-v1.pdf. Declercq, Eugene R., Lisa L. Paine, Diana R. Simmes, and Jeanne F. DeJoseph. 1998. “State Regulation, Payment Policies, And Nurse-Midwife Services.” Health Affairs 17 (2): 190-200. https://doi.org/10.1377/hlthaff.17.2.190. Edith Ramirez Chairwoman, Julie Brill, Maureen K Ohlhausen, and Joshua D Wright Commissioner. 2014. “Policy Perspectives: Competition and the Regulation of Advanced Practice Nurses.” https://www.ftc.gov/system/files/documents/reports/policy-perspectives-competition-regulation-advanced- practice-nurses/140307aprnpolicypaper.pdf. Jackson, Debra J., Janet M. Lang, William H. Swartz, Theodore G. Ganiats, Judith Fullerton, Jeffrey Ecker, and Uyensa Nguyen. 2003. “Outcomes, Safety, and Resource Utilization in a Collaborative Care Birth Center Program Compared With Traditional Physician-Based Perinatal Care.” American Journal of Public Health 93 (6): 999-1006. https://doi.org/10.2105/ajph.93.6.999. Johantgen, Meg, Lily Fountain, George Zangaro, Robin Newhouse, Julie Stanik-Hutt, and Kathleen White. 2012. “Comparison of Labor and Delivery Care Provided by Certified Nurse-Midwives and Physicians: A Systematic Review, 1990 to 2008.” Women’s Health Issues 22 (1): e73-81. https://doi.org/10.1016/j.whi.2011.06.005. Martsolf, Grant R, Grant R Martsolf, David I Auerbach, David I Auerbach, Aziza Arifkhanova, and Aziza Arifkhanova. 2015. “The Impact of Full Practice Authority for Nurse Practitioners and Other Advanced Practice Registered Nurses in Ohio:” Rand.Org. RAND Corporation. 2015. https://www.rand.org/pubs/research_reports/RR848.html. Miller, Amalia R. 2006. “The Impact of Midwifery-Promoting Public Policies on Medical Interventions and Health Outcomes.” Advances in Economic Analysis & Policy 6 (1). https://doi.org/10.2202/1538-0637.1589. Reid, M L, and J B Morris. 1979. “Perinatal Care and Cost Effectiveness: Changes in Health Expenditures and Birth Outcome Following the Establishment of a Nurse-Midwife Program.” Medical Care 17 (5): 491-500. https://www.ncbi.nlm.nih.gov/pubmed/107372. www.lao.ca.gov 27 analysis full gutter AN LAO REPORT Rosenstein, Melissa G., Malini Nijagal, Sanae Nakagawa, Steven E. Gregorich, and Miriam Kuppermann. 2015. “The Association of Expanded Access to a Collaborative Midwifery and Laborist Model With Cesarean Delivery Rates.” Obstetrics & Gynecology 126 (4): 716-23. https://doi.org/10.1097/aog.0000000000001032. Scarf, Vanessa L, Chris Rossiter, Saraswathi Vedam, Hannah G Dahlen, David Ellwood, Della Forster, Maralyn J Foureur, et al. 2018. “Maternal and Perinatal Outcomes by Planned Place of Birth among Women with Low-Risk Pregnancies in High-Income Countries: A Systematic Review and Meta-Analysis.” Midwifery 62 (July): 240-55. https://doi.org/10.1016/j.midw.2018.03.024. Snowden, Jonathan M., Ellen L. Tilden, Janice Snyder, Brian Quigley, Aaron B. Caughey, and Yvonne W. Cheng. 2015. “Planned Out-of-Hospital Birth and Birth Outcomes.” New England Journal of Medicine 373 (27): 2642-53. https://doi.org/10.1056/nejmsa1501738. Stange, Kevin. 2014. “How Does Provider Supply and Regulation Influence Health Care Markets? Evidence from Nurse Practitioners and Physician Assistants.” Journal of Health Economics 33 (January): 1-27. https://doi.org/10.1016/j.jhealeco.2013.10.009. Vedam, Saraswathi, Kathrin Stoll, Marian MacDorman, Eugene Declercq, Renee Cramer, Melissa Cheyney, Timothy Fisher, Emma Butt, Y. Tony Yang, and Holly Powell Kennedy. 2018. “Mapping Integration of Midwives across the United States: Impact on Access, Equity, and Outcomes.” Edited by Dongmei Li. PLOS ONE 13 (2): e0192523. https://doi.org/10.1371/journal.pone.0192523. Yang, Y. Tony, Laura B. Attanasio, and Katy B. Kozhimannil. 2016. “State Scope of Practice Laws, Nurse-Midwifery Workforce, and Childbirth Procedures and Outcomes.” Women’s Health Issues 26 (3): 262-67. https://doi.org/10.1016/j.whi.2016.02.003. 28 LEGISLATIVE ANALYST’S OFFICE analysis full gutter AN LAO REPORT www.lao.ca.gov 29 analysis full gutter AN LAO REPORT LAO PUBLICATIONS This report was prepared by Ben Johnson, and reviewed by Mark C. Newton and Carolyn Chu. The Legislative Analyst’s Office (LAO) is a nonpartisan office that provides fiscal and policy information and advice to the Legislature. To request publications call (916) 445-4656. This report and others, as well as an e-mail subscription service, are available on the LAO’s website at www.lao.ca.gov. The LAO is located at 925 L Street, Suite 1000, Sacramento, CA 95814. 30 LEGISLATIVE ANALYST’S OFFICE