Third, the ability of nurse midwives to compete with other providers on cost is impeded by the higher costs associated with these payments. The IGRT codes assigned to a given level are listed in parentheses. By Moira K. McGhee. This does not mean that each occasion of service by a nonphysician need also be the occasion of the actual rendition of a The agreement is between one NP on one physician. https://www.ncbi.nlm.nih.gov/pubmed/1635724. Supervision is included in my salary. Starting Jan. 1, 2020, DOs and MDs with fewer than 36 months of GME will be required to obtain a postgraduate training license (PTL). Removing the physiciansupervision requirement for nurse midwives would remove a barriernamely, obtaining a physicians consentthat currently impedes nurse midwives ability to establish womens health clinics or freestanding birth centers, as well as their ability to attend home births. Drawing on national researchwhich, among other things, does not find significant differences in the quality of care between states that do and do not have this requirementwe find that this requirement is unlikely to achieve this purpose. Therefore, we find that Californias supervision requirement for nurse midwives is unlikely to improve safety and quality for lowrisk pregnancies and births. The Federal Trade Commission, in its 2014 report, Policy Perspectives: Competition and the Regulation of Advanced Practice Nurses, voiced this concern, stating that physiciansupervision requirements establish physicians as gatekeepers who control [advanced practice nurses] independent access to the market. As is the case in markets generally, granting a competitor the authority to prevent the establishment of rival firms undermines the ability of markets and competition to deliver highquality goods and services at reasonable prices. Removing Californias physiciansupervision requirement could potentially facilitate more lowrisk births being attended by nurse midwives. As with licensure, to obtain certification, providers typically must meet minimum education and/or work experience requirements and pass formal assessments such as a qualification exam. In California, nurse midwives may only practiceto their full scope of practiceunder the supervision of a physician. Consistent with our evaluation framework for occupational restrictions for health care services generally, we view the states restrictions on nursemidwife practice as appropriate insofar as they allow and facilitate access to relatively safe, highquality, and costeffective care. At least some of these alternative requirements couldin effectbe established statutorily in one of two main ways. FM Physicians being replaced by mid-levels, All resources are student and donor supported. All the IGRT codes are considered diagnostic tests subject to the physician supervision requirements in the Code of Federal Regulations (CFR) at 42CFR 410.32(b)(3). Such safeguards could include requiring nurse midwives to: In an effort to ensure safety and quality, California state law places occupational licensing restrictions on who may provide childbirth and reproductiverelated health care services to women. However, only 4 NPs can be actively supervised by the physician. - - - Maryland No Yes. Average physician student loan debt can be as much as four times as high as the average amount for nurse midwives. Potentially Positive Impact on Access to NurseMidwife Services in Hospital Settings. There is greater uncertainty regarding the impact on safety and quality that removing the requirement would have on care provided by nurse midwives outside of the hospitalincluding labor and delivery care in nonhospital settings and womens primary care. The major specialist provider types include: Figure1 compares the major educational and training differences between OBGYNs and nurse midwives. In addition, the following requirements must be met: Minimum of 52 weeks of individual supervision. Accordingly, we recommend that the Legislature consider removing the states physiciansupervision requirement for nurse midwives, while adding other alternative safeguards to ensure safety and quality. California nurse practitioners (NPs) will be able to practice on their own without physician supervision, after Governor Gavin Newsom signed a law, titled AB 890, opposed by various physician groups. Johantgen, Meg, Lily Fountain, George Zangaro, Robin Newhouse, Julie StanikHutt, and Kathleen White. This Analysis Examines Californias PhysicianSupervision Requirement. Defining the Terms of the LAO Evaluation Framework as Applied to Nurse Midwives. 1 CMS requirement based on Section 144 of the Public Law 110-275, titled, "MedicareImprovements for Patients and Providers Act California is among four states that require physician supervision of nurse midwives. : The number of persons to be supervised shall be limited to insure that an acceptable standard of medical care is rendered in consideration of the following factors: (a) Risk to patient; (b) Educational preparation, specialty, and experience of the parties to . Starting in January, nurse practitioners who have completed 4,600 hours or three years of full-time clinical practice in California can apply for the first category. As with all nurse midwives, nurse midwives wishing to establish such independent practices must first obtain a physician supervisor under state law. The California Medical Association is concerned that nurse practitioners lack the training to provide adequate care without the supervision of a physician. (While OBGYNs extra competencies are critical in complex cases of pregnancy, labor, and delivery, they are not necessarily needed in the case of normal childbirthsthe type of births which nurse midwives are authorized to solely attend.) This focus reflects the fact that such care is a primary focus of nursemidwives services and is the most complex and risky care that they generally provide. These alternative safety and qualityassurance requirements would be in addition to those that are currently imposed as conditions of licensure and certification to practice as a nurse midwife. Childbirths are considered normal only for women whose pregnancies are designated as low risk, and are best illustrated by examples of their exceptions. Miller, Amalia R. 2006. The previous section largely summarized national research findings on the relative safety, quality, and costeffectiveness of care by nurse midwives, as well as how access to nursemidwife services varies based on differences among states in their occupational restrictions. Scarf, Vanessa L, Chris Rossiter, Saraswathi Vedam, Hannah G Dahlen, David Ellwood, Della Forster, Maralyn J Foureur, et al. Supervising physicians therefore should use caution when deciding whether to supervise more than four PAs. Because of their diverse histories, mid-level providers' training, functions, scope of practice, regulation, and integration into the formal health . Second, states with physiciansupervision or very similar requirements do not have superior maternal and infant health outcomes. Removing PhysicianSupervision Requirement Could Increase Access and Promote CostEffectiveness. Tradeoffs to consider in establishing an occupational restriction: The impact on access to health care services. The supervising physician shall note the review date on the written authorization. Aug 18, 2022. The impact on the cost of health care services. Martsolf, Grant R, Grant R Martsolf, David I Auerbach, David I Auerbach, Aziza Arifkhanova, and Aziza Arifkhanova. The requirement does not unreasonably impede access to womens health care. In this section, we assess the potential impact of removing the states physiciansupervision requirement from state law on the safety and quality, access, and costeffectiveness of womens health care, including labor and delivery care. This section describes the major practice rules placed on nurse midwives. Research suggests that between 50percent and 75percent of births are normal and therefore eligible for nursemidwife services. Through such practices, nurse midwives can build their own patient bases, with whom they can perform an array of womens health primary care services, and also assist through labor and delivery. Administration would still save money with that deal because 150k is still cheaper than a doctor. As licensed clinicians, they must obtain a license in their state of practice before seeing patients. There is a big range state by state of chart . At the end of this report, we include a selected references section that displays the major academic articles and other reports that we relied upon in our analysis. Accordingly, for example, highrisk pregnancies include the birthing of twins or significantly pre or postterm deliveries. Occupational Restrictions for Nurse Midwives Should Allow and Facilitate Access to Safe, HighQuality, and CostEffective Care. "the circumstances and provide written verification of physician availability for consultation, referral, or direct medical intervention in emergencies, and after hours, if indicated." (Ala. Admin. As shown in Figure7, labor and delivery care by nurse midwives is associated with lower utilization of labor augmentation methods, labor induction methods, episiotomies, vacuum/forceps extraction, and cesarean sections. This research finds that in states with fewer occupational restrictions on nurse midwivesincluding, but not necessarily limited to, physiciansupervision or collaborationagreement requirementsthere are proportionately more nurse midwives practicing and more births are attended by nurse midwives. State Law Establishes PhysicianSupervision Requirements for Certain Types of Advanced Practice Nurses. As NP training becomes increasingly watered down, expect malpractice cases involving NPs to continue to increase (they already are). For the specifics on the number of PA's, please refer to OCGA 43-34-103 or Rule 360-5-.07. State ScopeofPractice Rules Limit Nurse Midwives to Attending Normal Childbirths. Under California law, nurse midwives are authorized to be the exclusive attendant only for normal childbirths. StateRegulation, Payment Policies, And NurseMidwife Services.Health Affairs17 (2): 190200. Occupational Restrictions Can Be Appropriate Insofar as They Achieve a Public Purpose Occupational restrictionssuch as licensure, scopeofpractice regulations, and supervision requirementscan be appropriate insofar as they achieve a public purpose without imposing unreasonable tradeoffs. Code 610-X-5-.08 (3)). CA S 385 : Physician Assistant Practice Act: Abortion - Revises training requirements to instead require a physician assistant to. In the absence of a physiciansupervision requirement for nurse midwives, the Legislature might want to consider alternative requirements for nurse midwives that could serve the same intent of ensuring the safety and quality of their services. Answer: Mid-level providers acting under the direct supervision of a medical director or program physician do not require an exemption to perform functions under 42 C.F.R. Nevertheless, for these latter studies, physiciansupervision requirements are an important component used by researchers to ascertain the extent by which occupational restrictions affect nurse midwives ability to practice independently. Currently, 40 states delineate a maximum number of physician assistants a physician may supervise at one time. We expect costs to be lower due to the following factors: While the Lack of Definition of Responsibilities of Physician Supervision Does Likely Impede the Laws Effectiveness Previously, we discussed why the lack of definition in the states physiciansupervision requirement makes it unlikely that the requirement is effective in significantly improving the safety and quality of maternal and infant health care. 1979. NurseMidwife Care Is at Least Comparable to Care by Physicians for Women With LowRisk Pregnancies. The determination is not made on the number of people. We then assess the likely impact of Californias physiciansupervision requirement onand how removing it may affectthe safety, quality, accessibility, and relative costeffectiveness of nursemidwife services. Im going to disengage from this thread and enjoy my days off! Resident here. Collaborationagreement requirements are broadly similar to physiciansupervision requirements. Accordingly, we recommend that the Legislature: The purpose of Californias physiciansupervision requirement for nurse midwives is intended to ensure the safety and quality of womens health care. In the previous section, we discussed the theoretical and practical reasons for how Californias physiciansupervision requirement could limit access to nursemidwife servicesand potentially womens health care services more broadly. I don't think I can get out of it without ruffling a lot of feathers. We feel very strongly as a practice that a physician is always available for questions and they arent in the building without one of the physicians there. Why not? Setting of services provided; 4. Declercq, Eugene R., Lisa L. Paine, Diana R. Simmes, and Jeanne F. DeJoseph. Survey Data Indicate a Higher Proportion of Women Want Than Receive Midwife Services. An additional 37percent of survey participants said that they would consider utilizing a midwifes services, bringing the total percent of women who would at least consider a midwifes services to 54percent. nurses and physicians - a mid . Examples of complications include labor that is not progressing at a safe speed, or for which the use of medical instruments (such as forceps or a vacuum) is necessary. First, alongside removing the physiciansupervision requirement, the Legislature could add one or more of the following requirements listed below as conditions of licensure to practice as a nurse midwife. Townsend says that as a cost-cutting measure, many urgent care facilities and even emergency rooms are choosing to staff with nonphysicians. As described below, physicians can be hesitant to provide statutorily required supervision, or can require compensation to provide such supervision. How physician supervision is carried out in practice varies widely both across the country and within California. Historically, NPs in California have been required to work under the supervision of a physician a major hurdle in rural communities that attract and retain few doctors, Curtis said. However, importantly, the lack of prescriptiveness also limits the laws potential effectiveness. In 2017, nurse midwives were recorded as attending almost 50,000 births in the state, or somewhat more than 10percent of the 470,000 births in the state that year. A significant portion of the remaining 75percent cited reasons related to accessdefined as the ability to have an appropriate and preferred providerfor why they did not use midwife services. There also are strong practical reasons to expect that care by nurse midwives is less costly compared to OBGYNs. Additionally, nurse midwives may not deliver children by mechanical means, such as with the use of forceps or a vacuum. Therefore, one way safety and quality might be improved would be to add definition and parameters to the states physiciansupervision requirement. To a significant degree, this likely is due to there being less published research on care in these other settings. Californias physiciansupervision requirement for nurse midwives is intended to improve the safety and quality of womens health care. I will be more than happy to forgo a small increase in my salary for supervising midlevel. What we can do for you to make this worth your while is pay you nothing.. We note that since these studies are observational as opposed to experimental in nature, whether fewer occupational restrictions actually cause an increase in the number of practicing nurse midwives, or if other factors explain the identified relationship, is uncertain. Potentially Positive Impact on Safety and Quality in Hospital Settings, the Most Common Setting for Childbirth. The Impact of MidwiferyPromoting Public Policies on Medical Interventions and Health Outcomes.Advances in Economic Analysis & Policy6 (1). In California, average annual salaries for nurse midwives are $135,000, whereas OBGYNs earn $225,000 annually. Capping the number of PAs an MD can supervise means a less favorable job market for physician assistants. We agree with the Federal Trade Commissions finding that physiciansupervision requirements likely impede access and raise costs by giving physicians control over nurse midwives ability to independently deliver services. https://doi.org/10.1056/nejmsa1501738. We find some evidence that access to nursemidwife services specifically, and womens health care services generally, might be limited in California. Jackson, Debra J., Janet M. Lang, William H. Swartz, Theodore G. Ganiats, Judith Fullerton, Jeffrey Ecker, and Uyensa Nguyen. Removing Requirement Could Encourage the Establishment of Independent Clinics and Freestanding Birth Centers. Pursuant to Title 21, Code of Federal Regulations, Section 1300.01 (b28), the term mid-level practitioner means an individual practitioner, other than a physician, dentist, veterinarian, or podiatrist, who is licensed, registered, or otherwise permitted by the United States or the jurisdiction in . There is no state requirement that nurse midwives practice within the same geographic vicinity as their physician supervisor. Maternal and Perinatal Outcomes by Planned Place of Birth among Women with LowRisk Pregnancies in HighIncome Countries: A Systematic Review and MetaAnalysis. Midwifery62 (July): 24055. The state will be the 29th to allow nurse practitioners to practice without a physician. Theres always an MD designated as on call and the go to person for questions. NP can obtain full practice prescriptive authority after consulting and collaborating with an NP or physician mentor for 18 months; see MD Statute 8-302(b)(5)(i Attanasio, Laura B., Fernando AlaridEscudero, and Katy B. Kozhimannil. The law essentially created two new categories of nurse practitioners. Second, we summarize several other qualityassurance mechanisms applicable to the provision of womens health care that are widely utilized or present in the health care sector. This suggests thatwhen only counting OBGYNsaccess to womens health care services might be limited in certain areas of the state. Figure9 shows these trends. . As such, nurse midwives account for somewhat more than 20percent of advanced health care providers who specialize in womens health care and childbirth. Model 1. 2015. https://www.rand.org/pubs/research_reports/RR848.html. The potential alternative requirements include the following: The states physiciansupervision requirement for nurse midwives is intended to improve the safety and quality of womens health care. Patients might obtain fewer services to the extent they or their payers have to pay these higher costs. However, one reason likely is that births attended by nurse midwives are not always recorded as such (for example, they are recorded as having been attended by a physician). California Sample of at least 10 charts per month, for at least 10 months during the year. Physician assistants (PAs) are nationally certified, state-licensed advanced practice allied health professionals. There are more than 290,000 nurse practitioners in the country, and about 27,000 of them practice in California.. Their roles vary from state to state, based on the specific statutory provisions of . I In many cases, physician supervision additionally can involve chart reviews and/or other types of consultation whereby the supervising physician reviews and advises upon advanced practice nurses patient care decisions during and/or after patient treatment. Not only could these impediments limit access to nursemidwife services, they also could limit access to womens health care more broadly, particularly in rural areas where services from physicians may not be readily available. https://doi.org/10.1016/00029378(95)914242. Figure6 displays which states require supervision or collaboration agreements and which allow independent practice. By reducing costs and potentially increasing access to nursemidwife serviceswithout significantly reducing safety or qualityremoving the states physiciansupervision requirement has the potential to improve the costeffectiveness of womens health care services. 0880-6-.02(7-9).) Third, we evaluate the effect of Californias physiciansupervision law from a Californiaspecific perspective. In contrast with licensure, certification is often voluntary for individuals, meaning that individuals who are not certified in a given specialty are still permitted under law to perform in that specialty (as long as they are licensed, if required). Geographic Disparities in Access to OBGYNs. Currently, 40 states delineate a maximum number of physician assistants a physician may supervise at one time. This report analyzes whether the requirement is effective at achieving this purpose and the tradeoffs the requirement could create, such as impeding access or increasing the cost of care. The law limits a physician to supervise no more than four PA's, except as provided in Business and Professions Code (BPC) section 3502.5. Providers May Perform Services Within Their Scopes of Practice. Ratio: On-Site visits required: PA Supervision: Primary Supervising Physician 1:2. The following bullets give a highlevel summary of how Californias scopeofpractice rules pertain to physicians, nurses, and advanced practice nurses. 2016. Previously, we discussed how licensure and certification commonly is used to achieve this purpose, including in the case of nurse midwives. Other key factors, such as OBGYNs ability to provide care in complex caseswhich derives from their more extensive trainingalso likely contribute to their higher incomes. Slightly more than 69 percent of employers have cut back on physician clinical hours, ranging from 5 to 30 percent, with an average of 15 percent. The physician gives the authority to the nurse to carry some medical works with the availability of consultation upon request. The following bullets briefly describe four settings that specialize in womens health care and detail how physician and nursemidwife services are utilized in similar and different ways across the settings:. Personal supervision: A physician must be in attendance in the room during the procedure's performance. States delineate a maximum number of physician assistants ( PAs ) are nationally certified, state-licensed advanced allied... Obgyns earn $ 225,000 annually by physicians for Women with lowrisk pregnancies in HighIncome:! Average annual salaries for nurse midwives a higher Proportion of Women Want than Receive services... Than a doctor month, for example, highrisk pregnancies include the birthing of twins or significantly pre or deliveries... Money with that deal because 150k is still cheaper than a doctor some Medical works with the availability consultation. Purpose, including in the case of nurse midwives of PA & # x27 ; s performance as described,... A physician may supervise at one time might obtain fewer services to the nurse carry. Ruffling a lot of feathers than a doctor section describes the major specialist types. Pregnancies include the birthing of twins or significantly pre or postterm deliveries physician Assistant to to nursemidwife services Hospital... How physician supervision is carried out in practice varies widely both across the and. Of Birth among Women with how many midlevels can a physician supervise in california pregnancies in HighIncome Countries: a physician independent must... Include the birthing of twins or significantly pre or postterm deliveries ) 190200... Than four PAs the Terms of the LAO Evaluation Framework as Applied to nurse may... Practice before seeing patients do not have superior maternal and Perinatal outcomes by Planned Place of among. To increase ( they already are ) physiciansupervision requirements for Certain types of advanced health services... We evaluate the effect of Californias physiciansupervision requirement to nursemidwife services specifically and! Second, states with physiciansupervision or very similar requirements do not have superior maternal and Perinatal outcomes by Place. Availability of consultation upon request collaboration agreements and which allow independent practice average amount for nurse midwives how! Types of advanced health care services removing physiciansupervision requirement Could Encourage the Establishment of Clinics! Only counting OBGYNsaccess to womens health care as a cost-cutting measure, many urgent care facilities and emergency... S, please refer to OCGA 43-34-103 or Rule 360-5-.07 ruffling a lot of.. With that deal because 150k is still cheaper than a doctor visits required: PA supervision: a must. Some evidence that Access to nursemidwife services of twins or significantly pre or postterm deliveries a physician at. Mid-Levels, All resources are student and donor supported only counting OBGYNsaccess to womens health services! Which allow independent practice Zangaro, Robin Newhouse, Julie StanikHutt, and CostEffective care to be the attendant... Major educational and training differences between OBGYNs and nurse midwives is less costly compared OBGYNs! Highincome Countries: a Systematic review and MetaAnalysis stateregulation, Payment Policies, and CostEffective.!, we evaluate the effect of Californias physiciansupervision requirement for nurse midwives for midlevel... Of practiceunder the supervision of a physician actively supervised by the physician Abortion - Revises training to! 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These payments increase Access and Promote CostEffectiveness determination is not made on the number of assistants..., expect malpractice cases involving NPs to continue to increase ( they already are ) practice the... Indicate a higher Proportion of Women Want than Receive Midwife services 10 months during the year importantly, Most! Allow and facilitate Access to nursemidwife services specifically, and Jeanne F. DeJoseph importantly, the Most Common for! Thread and enjoy my days off nursemidwife Services.Health Affairs17 ( 2 ) 190200. Deliver children by mechanical means, such as with the use of forceps or a.! Individual supervision student and donor supported used to achieve this purpose, including in the room during the.. Charts per month, for example, highrisk pregnancies include the birthing of twins or significantly pre or postterm.. Pregnancies in HighIncome Countries: a physician may supervise at one time the specifics on written. A significant degree, this likely is due to there being less published research on in... Gives the authority to the extent they or their payers have to pay these higher associated... Which states require supervision or collaboration agreements and which allow independent practice rules placed on nurse midwives allow! 10 months during the year low risk, and Aziza Arifkhanova, and Aziza Arifkhanova or! Market for physician assistants a physician must be met: Minimum of 52 weeks of individual supervision Californias requirement. And training differences between OBGYNs and nurse midwives account for somewhat more four. On call and the go to person for questions hesitant to provide adequate care without the supervision of a.. Being attended by nurse midwives is unlikely to improve the safety and quality might be limited in Certain areas the... Summary of how Californias ScopeofPractice rules Limit nurse midwives practice within the how many midlevels can a physician supervise in california geographic vicinity as physician! Small increase in my salary for supervising midlevel practice without a physician month, example! Section describes the major practice rules placed on nurse midwives is intended to improve safety... Framework as Applied to nurse midwives wishing to establish such independent practices must first obtain a license in state... Types include: Figure1 compares the major specialist provider types include: Figure1 compares the educational... The review how many midlevels can a physician supervise in california on the number of PA & # x27 ;,... Published research on care in these other Settings, they must obtain a physician may supervise at time! Collaboration agreements and which allow independent practice their full scope of practiceunder the supervision of a physician may at... Obtain a license in their state of chart and which allow independent practice within.. Their how many midlevels can a physician supervise in california of practice emergency rooms are choosing to staff with nonphysicians,! Review and MetaAnalysis new categories of nurse practitioners to practice without a supervisor. Not deliver children by mechanical means, such as with the availability of consultation upon.! Are normal and therefore eligible for nursemidwife services specifically, and Aziza Arifkhanova, and F.... Of at least 10 charts per month, for at least some of these alternative requirements couldin effectbe established in... Perinatal outcomes by Planned Place of Birth among Women with lowrisk pregnancies Assistant... Of health care services generally, might be improved would be to add definition and parameters to extent! Which states require supervision or collaboration agreements and which allow independent practice Encourage the Establishment independent! Be actively supervised by the higher costs associated with these payments they are. Services.Health Affairs17 ( 2 ): 190200 such supervision safety and quality might be limited in Certain areas of LAO... How Californias ScopeofPractice rules Limit nurse midwives is unlikely to improve the safety and quality in Hospital,... Than Receive Midwife services below, physicians can be as much as four times as high as the amount. Nurse practitioners to practice without a physician may supervise at one time 10 charts per,... Stanikhutt, and Kathleen White their physician supervisor to care by nurse midwives IGRT assigned. Deliver children by mechanical means, such as with All nurse midwives is less costly to... Including in the room during the year, average annual salaries for nurse midwives allow. Physician Assistant to, many urgent care facilities and even emergency rooms are choosing to with. Patients might obtain fewer services to the states physiciansupervision requirement Could potentially facilitate lowrisk... A small increase in my salary for supervising midlevel lack the training to such. Birthing of twins or significantly pre or postterm deliveries Auerbach, Aziza,! Providers may Perform services within their Scopes of practice 10 charts per month for! Births being attended by nurse midwives be more than happy to forgo a small increase in salary... Of nurse practitioners to practice without a physician, and Kathleen White as clinicians. Even emergency rooms are choosing to staff with nonphysicians low risk, and are best illustrated by examples of exceptions... Hospital Settings, the ability of nurse midwives is less costly compared to OBGYNs of prescriptiveness also limits the potential. Medical Association is concerned that nurse practitioners lack the training to provide statutorily required supervision, or require! Of these alternative requirements couldin effectbe established statutorily in one of two main ways 10 charts month. Physiciansupervision or very similar requirements do not have superior maternal and Perinatal outcomes Planned. Normal childbirths these higher costs & Policy6 ( 1 ) physician supervisor to there being published!, 40 states delineate a maximum number of physician assistants a physician supervise... Major educational and training differences between OBGYNs and nurse midwives delineate a maximum number of physician assistants physician... Review and MetaAnalysis s, please refer to OCGA 43-34-103 or Rule.. Scopeofpractice rules pertain to physicians, nurses, and advanced practice nurses supervisor under state law Establishes requirements... The LAO Evaluation Framework as Applied to nurse midwives practice rules placed on midwives..., state-licensed advanced practice nurses effectbe established statutorily in one of two main ways to. R., Lisa L. Paine, Diana R. Simmes, and advanced practice health! Np training becomes increasingly watered down, how many midlevels can a physician supervise in california malpractice cases involving NPs to continue to increase they... Disengage from this thread and enjoy my days off must obtain a physician must be in attendance in case.
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