ACNM keeps abreast of state-level developments related to midwifery and women’s health care. Below please find highlights of some recent activity of interest, including links to additional information.
2010 Legislative Developments
Below is a sampling of bills affecting CNM/CM practice offered for consideration during the 2010 state legislative sessions. For full text of each introduced measure that is available, please click on bill number for hypertext link.
New York has repealed the written practice agreement requirement. A. 8117-B enjoyed overwhelming legislative support and was signed into law by Governor Paterson on July 30, 2010. Read ACNM's press release urging passage of the bill. ACNM had also issued correspondence specifically tailored to legislators and the Governor.
North Carolina has authorized a study of greater flexibility in CNM practice.
Maryland published a rule eliminating the requirement for a signed collaborative agreement between a CNM and physician; the rule took effect June 28, 2010.
New Jersey Acts to Eliminate Collaborative Agreement Requirement for CNMs and CMs and Simplify CNM Prescriptive Authority
Final rules effective June 21, 2010 jettison the signed collaborative agreement requirement barrier to CNM/CM practice and streamline prescriptive authority requirements for CNMs. ACNM submitted formal comments to the State Board of Medical Examiners urging adoption of the amendments, and encouraged members, particularly practitioners in New Jersey, as well as hospital administrators and physicians with whom they are affiliated, to also provide personalized letters in support.
Minnesota has enacted an omnibus budget bill authorizing licensure of birth centers. Midwives advocating for the measure also were successful in fending off a last-minute proposed cut in Medicaid reimbursement that would have been tied to the current Medicare rate by invoking the new federal health care law increase in Medicare reimbursement. (See H.F. 0001 for full text). Also see blog entry about the bill from Brielle Stoyke, Government Affairs Committee Representative.
Colorado enacted S. 176, addressing requirements for APN inclusion in the advanced practice registry.
A law in Washington (S. 6627) authorizes pharmacies to fill prescriptions written by advanced registered nurse practitioners licensed in other states or in certain Canadian provinces.
A law in Oklahoma (S. 1817) specifically names midwives among birth attendants responsible for treating infants’ eyes with a prophylactic ophthalmic agent recommended by the Centers for Disease Control and Prevention.
South Dakota (S.96) lifted the sunset of a provision exempting CNMs attending homebirths from the collaborative agreement requirement.
The attorney general of Tennessee has issued an opinion affirming that state law clearly confers CNM prescription-writing authority. The formal opinion had been sought during tamper-resistant prescription rulemaking when the state medical society questioned whether such authority applied to all categories of advanced practice nursing.
New JerseyA. 1392/S.1526 includes midwives among enumerated licensed professionals who may provide an affidavit of merit in professional liability actions brought against a midwife. The Assembly bill has passed the Assembly.
Bills that failed to gain approval during 2010 sessions:
KansasH. 2447 would: replace the current naming convention of “advanced registered nurse practitioner” (ARNP) with “advanced practice registered nurse” (APRN); specify that APRNs may serve as primary care providers of record; and direct rulemaking to require “graduation from or completion of a Master’s or higher degree in one of the advanced practice registered nurse roles approved by the BON” as prerequisite for new applicants for APRN licensure.
The bill did not advance in time for the crossover deadline.
KentuckyS. 75 would eliminate the mandate that advanced registered nurse practitioners enter into a collaborative agreement with a physician to prescribe or dispense nonscheduled drugs. The measure also removes the requirement that the Board of Nursing establish limits for specified controlled substances while leaving in place its authority to do so.
WisconsinA. 675, would eliminate the collaborative agreement requirement, clarify professional liability insurance options and expand hospital privileging availability. The bill underwent a series of amendments and was approved by the Assembly, but did not progress by the time the session ended for the year.
NebraskaLB 827 would obligate CNMs to meet certain continuing competency requirements in order to renew prescriptive authority. Bills to eliminate the supervisory collaborative practice requirement (LB 457), enhance access to hospital privileges (LB 406), and allow CNM attendance at home birth (LB 481) received public hearings, but did not advance.
A bill in Washington, S. 6708, includes ARNPs among enumerated respiratory care practitioners and delineates aspects of respiratory care practice.
A New Mexico bill, H. 221, would consolidate all regulatory oversight of health care practitioners under the board of medicine.
2009
A rule change in Kansas clarified the role of a CNM in functioning not as part of an interdependent member of a physician-directed team, but in providing independent nursing diagnosis and developing and managing the medical plan of care based on the authorization of collaborative practice.
ACNM provided testimony in support of a troika of Nebraska bills to improve the practice environment for CNMs by eliminating the supervisory collaborative practice requirement (LB 457), enhancing access to hospital privileges (LB 406), and allowing CNM attendance at home birth (LB 481).
New Jersey Enacts Two Laws Enhancing Access to Midwifery Services
One requires health insurers to reimburse obstetrical providers—including CNMs and CMs—in installment payments for maternity services provided over the term of a woman's pregnancy, rather than after the birth of the child. Covered payments include office visits, other pre-natal care, and delivery of the baby. Learn more.
The other adds CNMs to the list of professionals who can certify medical conditions of individuals under New Jersey's "Temporary Disability Benefits Law" and "Work First New Jersey Act. Learn more.
New York has enacted a new law that sets forth a “Breastfeeding Mothers’ Bill of Rights.” Among enumerated principles are rights to have the baby stay with the mother “right after birth,” and to have trained personnel help if there are difficulties with breastfeeding. Statements of rights must be conspicuously posted. For more information, view full text of new law.
New York has also banned the shackling of pregnant prisoners in custody in the criminal justice system. The law, which took effect upon its signing on August 26th, will prevent pregnant prisoners from being shackled or handcuffed during medical visits, while they are in labor or during recovery after giving birth. Texas, Illinois, California, Vermont and New Mexico have similar protections in law. For more information, view full text of new law.
North Carolina Authorizes Study of CPM Licensure; Considers Study to Afford CNM Practice Greater Flexibility
On Sept. 10, North Carolina enacted an omnibus law authorizing a number of studies. One of the provisions provides that “the NC Joint Midwifery Committee may develop and propose a methodology for licensing Certified Professional Midwives (CPMs) in the state. In developing a licensure methodology, the Committee may collaborate with the North Carolina Obstetrical and Gynecological Society, the North Carolina Section of the American College of Obstetricians and Gynecologists, and other interested parties. The proposed methodology may establish standards for education and training of CPMs that are at least as stringent as those put forth by the American Midwifery Certification Board and may require that CPMs maintain insurance liability coverage regardless of the setting in which they practice. The Commissioner of Insurance may provide the Committee with information relating to the access and availability of such insurance in North Carolina. The Committee may report its recommendations and legislative proposals to the 2010 Regular Session of the 2009 General Assembly on or before its convening.” Action is still pending on a bill that would allow the Legislative Research Commission to study options for making CNM practice more flexible. Once authorized, studies cannot go forward absent specific allocation of funds.
Two Laws in North Dakota Bolster Midwifery S. 2227 expands “medical loan repayment program” funding available to CNMs while S. 2158 obligates the state Medicaid program to recognize CNMs as primary care providers with the same rights and responsibilities afforded primary care physicians.
AMA Checklist Prompts Comment Letter
The American Medical Association (AMA) House of Delegates did not consider any anti-midwifery resolutions at its annual meeting in June; however, there was a presentation of an internal study report from its Board of Trustees to the House of Delegates of a checklist of factors physicians should consider prior to entering into collaborative practice agreements with advanced practice nurses, a group of practitioners the report refers to as "physician extenders." Though no action resolutions accompanied the report, the tone of the recommendations to physicians could have a chilling effect on midwifery practice. ACNM and other organizations representing advanced practice nursing disciplines have signed a comment letter voicing objection.
Hawaii Mandates Insurer Recognition of CNMs as Primary Care Providers
The new legislation also confers global signature authority for needed verification related to worker’s compensation and physical examination forms, and makes common sense amendments to prescriptive authority to facilitate seamless access to care. Read full text of the law.
Pennsylvania Publishes Final Rule Authorizing CNM Prescription-Writing
On April 4, the Pennsylvania State Board of Medicine (BOM) published its final implementing regulations for prescriptive authority for CNMs to take immediate effect. The rules bring an end to a process that had its formal start with the enactment of authorizing legislation in 2007, but had been delayed at the end of 2008 by politicking. With this final regulatory action, Pennsylvania becomes the last state in the nation to implement prescriptive authority for nurse-midwives. For more information, see the new rules. Additional guidance for making application to the BOM for prescriptive authority will be forthcoming from the Pennsylvania State Board of Medicine.
ACNM Deepens Commitment to Fight Scope of Practice Infringements
ACNM has stepped up its involvement in the Coalition for Patients’ Rights (CPR) by joining the group’s steering committee to help the effort reach a broader audience, including policymakers, insurers, health care providers and the general public. CPR consists of numerous organizations representing a variety of non-physician health care professionals who provide a diverse array of safe, effective, and affordable health care services to millions of consumers each year. The Coalition’s members work to ensure that the practitioners they represent do not face unwarranted scope of practice restrictions based upon ill-founded AMA House of Delegates resolutions or similar measures. For more information, read ACNM's letter of support or visit the CPR Web site.
New Missouri Law Grants CNMs Controlled Substances Prescriptive Authority
A new law in Missouri authorizes certified nurse-midwives (CNMs) to prescribe controlled substances in Schedules III through V, with prescribing of Schedule III narcotic controlled substances limited to a 120-hour supply with no refills. Signed by the Governor on June 10th, the law will take full effect on January 1, 2009. Only two other states in the nation still fail to confer controlled substances prescription-writing privileges to CNMs -- Florida and Alabama.
ACNM Opposes AMA House of Delegates Resolution
ACNM has submitted commentsin opposition to the American Medical Association House of Delegates' proposed resolution to allow nurses holding Doctor of Nursing Practice (DNP) degrees to practice only under physician supervision.
South Dakota Law Allows CNM-assisted Out-of-Hospital Birth
South Dakota Senate Bill 34, allowing CNMs to provide out-of-hospital birth services, was signed
into law on March 13th. The bill authorizes the State Medical and Nursing Boards to grant a waiver of the collaborative agreement requirement, providing specific practice guidelines to be established by the
Boards are followed. The bill is set to sunset on June 30, 2013.
New Mexico Law Brings Malpractice Premium Relief
New Mexico House Bill 167 creates the "Birthing Workforce Retention Fund" in the state treasury to assist CNMs and physicians with malpractice premiums when those costs jeopardize their ability to practice in the state. Eligible providers must show that low-income clients make up at least 1/2 of OB practice and that premiums have increased every year for two years. The bill was signed into law on February 29th as Chap.73.
ColoradoLaws Improve CNM Practice Environment
On March 20th, three key bills became law in Colorado. Flanked by nurse-midwives who supported the advancements, Governor Ritter signed into law bills expanding reimbursement eligibility under the state Medical Assistance Act, allowing signatures on various health-related legal documents and ensuring objective criteria for health plan consideration of preferred provider applications.
Colorado Executive Order Directs Collaborative Scopes of Practice Study
Colorado Executive Order B003 08 was issued by Governor Ritter on February 7th, commissioning a study of collaborative scopes of care and creating the Collaborative Scopes of Practice Advisory Committee. Barbara Hughes, CNM, has been named the designated CNM APN appointee on the 12-member committee. The Committee will review research regarding expanding and collaborative scopes of practice for APNs, PAs, and dental hygienists. The study is geared toward identifying systems and settings in which high quality care can be provided by non-physicians and non-dentists to meet the state's provider needs. A report is due to the Governor and legislature by December 31, 2008.
ACNM urged reversal of Alabama Board of Medical Examiners rulemaking surcharging physicians in collaborative practice with CNMs $100.00 per collaborative agreement per year. (See ACNM letter urging reversal of policy). The final rulemaking kept this needlessly restrictive provision.
The Advocate: Read updates on legislative and regulatory news in each month's edition of The Advocate. Our government relations newsletter is published monthly and contains state and federal legislative, regulatory and advocacy information. (PLEASE NOTE: The last issue of the Advocate was published in December 2008.)
TORT REFORM:
Like their physician colleagues across the country, CNMs/CMs are experiencing a professional liability crisis. Many forces that are beyond our control are forcing ACNM members to become experts in this complex topic. In order to meet this critical need for information, ACNM has published a Professional Liability Packet, which was updated in 2007. (Due to its large file size, the Packet has been divided into four parts.)
The Consensus Model was developed by a group of Advanced Practice Nursing (APRN) organizations including ACNM, several nurse practitioner organizations, clinical nurse specialists, and nurse anesthetists.
