Nebraska legislators are considering a bill that would allow certified nurse-midwives to practice without physician supervision. State and national physician organizations opposing the measure have underscored both their commitment to physician-led, team-based health care and strong objections about treatment delivered outside that model.
"Nurse midwives are valued members of the health care team. They are well trained for low-risk deliveries, which works well within the team structure,” said Nebraska Medical Association President Todd Pankratz, MD, about Legislative Bill (LB) 466. “As a result, we would encourage continued collaboration between physicians and nurse midwives and feel that LB 466 would hinder this team-based approach."
The bill is currently in the Legislature’s Health and Human Services Committee. If not put before the full Legislature before its recess in June, it could still be taken up when lawmakers meet again in January. In 2015, independent practice for nurse practitioners became law in the state. The year before, the state’s outgoing governor vetoed such a measure.
In a letter to the committee chair, the AMA voiced its own opposition to LB 466 and in support of team-based care and the physician leadership role in it. “This bill would allow certified nurse-midwives (CNMs) to practice independent of physician supervision, collaboration or oversight. As a result, LB 466 would give would give CNMs expanded authority to diagnose, treat and prescribe,” wrote AMA CEO and Executive Vice President James L. Madara, MD. He emphasized that “Nebraska’s patients need health care professionals to work together.”
The AMA’s opposition to the Nebraska bill is consistent with its approach nationally to “oppose scope of practice expansions by nonphysician providers that threaten the health and safety of patients.”
Dr. Madara warned the independent-practice approach “would further compartmentalize and fragment health care delivery.” In contrast, maintaining the standard of physician-led team-based care “would foster integration and coordination,” he wrote. The letter also speaks to a common argument in favor of expanded scope of practice for nonphysicians—that it would make care more accessible. “As data suggest, CNM independent practice does not lead to increased access to care or greater distribution of health care professionals.”
Dr. Madara addressed keys factors that demonstrate why “physicians are uniquely qualified to lead the health care team.”
There is a stark difference in the time and depth of the training between physicians and CNMs. The path to becoming a physician entails more than 10,000 hours of clinical education and training. Residencies can last from a minimum of three years to as many as seven, on top of four years of medical school. “In comparison, CMNs have only between 500–720 hours of advance nursing education and training,” Dr. Madara pointed out, detailing the disparities in qualifications.
“Physicians’ education, clinical training and continuing medical education ensures that they are well equipped to diagnose and manage patient care,” he wrote, adding, “Patients want physicians to lead the health care team.”
The AMA has surveyed patient preferences in terms of how their care should delivered. Ninety-eight percent of patients said physicians and nurses need to work together to get patients the care they need.
In terms of the physician’s role, 91 percent of respondents considered a physician’s education and training “vital,” all the more so if there is a complication or medical emergency. Eighty-six percent acknowledged the benefit of a physician’s team leadership for patients with chronic conditions or comorbidities. “Four of five patients prefer a physician to have primary responsibility for leading and coordinating their health care,” according to the letter.
