Appendix F.  New CNM Scope Index Calculations

This appendix contains a table that documents the detailed calculations used to compute the new professional practice index for CNMs for each of the 50 States plus the District of Columbia.

Legal Status (Maximum = 35)

Title protection indicates acceptance and acknowledgement of the skills required to practice as a professional. Legal protection provides a safeguard for both the public and the practicing professional.

CNMs are licensed, certified, or approved in all fifty States and the District of Columbia. Licensure as a nurse midwife provides recognition of the status of the profession. CNMs are frequently regulated as a category of Advanced Practice Nurse (APN). They are sometimes addressed as a separate category within the statutes and regulations which speak to professional practice, licensure requirements, and prescriptive authority. In some States, Midwives or CNMs are considered independently from other nurses and are regulated as a separate profession from APNs.

Regulation by the Board of Nursing is the most common structure when CNMs are considered to be APNs. Separate regulation by a Board of Midwifery is considered ideal since a separate board can best represent the interests and the orientation of midwives. When midwives are regulated by a separate entity, non-nurse midwives may be included in the rules.

Gynecological care in statute or regulation suggests that midwives are viewed as practicing in an expanded role. Limiting midwives to care in pregnancy and at birth does not fully use their professional competencies.

The nature of midwifery practice demands a relationship with a physician. Complicated pregnancies and deliveries require the availability of specialty physicians with the skills to provide needed patient care. Practice as a self-employed (autonomous) midwife is an option in several States, but the need for a collaborating physician is universal. Practice agreements and review of records that are left to the discretion of the midwife and the physician acknowledge the competency and skill of each profession and the ability of both to safely meet patient need.

Temporary permits allow nurse midwives awaiting the results of the certification examination to practice.

Inactive or retired status allows non-practicing CNMs to use their title.

The profession of Midwifery philosophically supports non-nurse midwives who are properly trained and regulated. The roots of midwifery practice are in the care of women during pregnancy and childbirth in communities where other medical resources are limited. Requiring a masters degree, although elevating to a profession, limits the ability of non-nurse midwives (also referred to as direct entry or lay midwives) to provide care. Rather, professional midwifery associations support adequate skill and competency in midwifery and have opened their certification examinations to these midwives.

Hospital privileges permit a nurse midwife to admit a patient without a supervising physician and provide autonomy to the professional. Signing birth certificates and the ability to directly refer indicate recognition of the professional ability of the midwife.

Reimbursement (Maximum = 35)

In 1997, the Balanced Budget Act, expanded the locations at which CNM could be reimbursed for services. Since this was a progression in reimbursement from 1992, a score was awarded to every State for direct Medicare payment.

State reimbursement policy for payment of services rendered to Medicaid-eligible patients varies considerably by State and by profession.

The legal right to be reimbursed for services provided is critical to the autonomy of CNMs. Although services may be provided totally by the CNM, the inability to bill third parties for payment as an identified provider can be a barrier to the provision of care.

Direct access legislation allows women to choose well care services from a nurse midwife. Legislation enabling that independent choice acknowledges the skill of the CNM and suggests the roles that CNMs can play in healthcare delivery.

Prescriptive Authority (Maximum = 30)

When prescriptive authority is granted as part of the licensure process for nurse midwives, it is recognition of confidence in the education and skill of the CNM. The necessity of a separate application for prescriptive privilege suggests special requirements for the authority not fundamental to the didactic and clinical preparation of the midwife.

Although DEA numbers are a requirement for prescribing controlled substances, a separate score was allotted to emphasize the importance of the privilege of writing scripts for scheduled drugs.

Definition of the prescriptive privilege in law rather than by individual physicians suggests full recognition of the capability of the professional. Dependence for prescriptive authority on physician delegation limits the nurse midwife by creating barriers to efficient practice. Review with another health professional of patient needs and ordering of appropriate medications is a necessary part of practice. However, the circumstances under which that consultation occurs may best be determined by the midwife and may not need to be detailed in law or in a cooperative agreement.

The ability to receive and distribute sample medications, to independently sign a prescription and to prescribe medical devices are suggestive of recognition of the expertise of nurse midwives.

Continuing education requirements maintain the skill of the professional and update competencies.

The actual point allocations for the 50 States are presented below.

FOOT NOTES

ALABAMA:
b) Certification of Qualification
d) One midwife on Joint Practice Committee
n) Lay midwives with permit may practice but DOH has no present method for issuing permits; the statute is inactive (ACNM)
o) Plan for review of records required in regulations
r) Referral in definition of practice
ALASKA:
a) ANP title only,includes CNM
I,j,m) Procedures for consultation referral must be filed with BON but no direct relationship required
n) Certified Direct Entry (CDEMs) Midwives regulated by Board Of Certified Direct Entry Midwives (ACNM)
r) Referral to other health care professionals
u) Any Willing Provider Law
v) No managed care in Alaska, direct access implied by independent nature of practice
z) Dispensing authority as of 1994
ARIZONA:
a) RNP title protected includes CNMS
b) Certified to practice
c) Category of RNP
g) After 2001
j) All acts performed must be in collaboration with a physician
k) RN temporary license
n) Midwifery regulated by DOH Nurse Midwives by BON
p) Scope of practice in statute includes admitting patients to hospitals
s) Arizona has an innovative managed care plan called Arizona Health Cost Containment System that covers medicaid eligibles, pregnant women etc. RNPs can contract with the plan
z) Prescribe and dispense -limits on refills
^) No physician collaboration required on Application for Authority
ARKANSAS:
a) CNM
m) For intrapartum care and prescriptive authority only
n) Lay midwives regulated by state DOH (ACNM)
q) Licensed midwifery statute provides this privilege
r) Referrals in definition of practice
w) Granted a certificate of prescriptive authority
CALIFORNIA:
a) Holding oneself out as CNM without certification is grounds for discipline
b) Certificate to practice
d) BON with Midwifery Committee
k) Not necessary because of various avenues available for certificates to practice
m) Standardized procedures which are protocols for medical acts including prescribing provide guidelines for practice
n) Licensed midwives are regulated by Division of Licensing of Medical Board since 1993 (ACNM)
p) RNs may be granted expanded role privilege in hospitals
z) Medically delegated
COLORADO:
b) Registration
g) For prescriptive authority and beginning 7/1/2008 required
I) Direct entry midwives are licensed and regulated under Colorado Medical Practice Act
J) 2000 legislation changed language to collaboration
n) Supervisory language for medical functions, collaborative language for prescriptive authority
r) In definition of collaborative agreement
z) Dispensing limited to prepackaged samples, prescriptive authority limited to acute self limiting condition, chronic condition, terminal comfort care
^) Name of at least one collaborating physician required

REFERENCES

Main Resources

American College of Nurse Midwives, Nurse Midwifery Today, A Handbook of State Laws and Regulations 2000, Washington, DC, 2000.
Buppert C, Nurse Practitioner’s Business Practice & Legal Guide, Aspen Publications, Gaithersburg, Maryland, 1999.
Cooper RA, Multidisciplinary Healthcare Workforce Data Consortium, Meeting, April 2001, Washington, DC.
Henderson T, Chovan T , Removing Practice Barriers of NonPhysician Providers, Intergovernmental Health Policy Project, The George Washington University, February 1994.
Henderson T, Fox-Grage W, Lewis S, Scope of Practice & Reimbursement for Advanced Practice Registered Nurses, Primary Care Resource Center, Intergovernmental Health Policy Project, The George Washington University, December 1995.
Henderson T, Norris S, National Conference of State Legislators, Inc.
National Council of State Boards of Nursing, http://www.ncsbn.org.
National Council of State Boards of Nursing, The Regulation of Advanced Practice Registered Nurses 1997, Chicago, IL, 1998.
Pearson LJ. Annual Legislative Update: How Each State Stands on Legislative Issues Affecting Advanced Nursing Practice, The Nurse Practitioner 26(1):7-57.
US Department of Justice, Drug Enforcement Administration, Diversion Control Program, http://www.deadiversion.usdoj.gov/drugreg/practioners/index.html.
Washburn University School of Law, http://www.washlaw.edu
ALABAMA
Alabama Board of Nursing, http://www.abn.state.al.us
ALASKA
Alaska Legislature Online, http://www.legis.state.ak.us
Alaska Division of Occupational Licensing: Board of Nursing, http://www.dced.state.ak.us/occ
ARIZONA
Arizona Health Care Cost Containment System, http://www.ahccs.state.az.us
Arizona State Board of Nursing, http://www.azboard of nursing.org
ARKANSAS
Arkansas State Board of Nursing , http://www.accessarkansas.org/nurse
CALIFORNIA
State of California-State and Consumer Services Agency, Board of Registered Nursing, http://www.rn.ca.gov
National Council of State Boards of Nursing, http://www.ncsbn.org
American College of Nurse Midwives, http://www.acnm.org
COLORADO
Colorado Department of Regulatory Agencies, http://www.dora.state.co.us/Nursing

FOOT NOTES

CONNECTICUT:
c) Midwifery Practice Act
d) Department of Public Health and Addiction Services, a committee of 3 CNMs
serves as advisory panelI) Clinical practice relationship with OB/GYN required
j) Services "directed" by a qualified OB/GYN however, statute indicates this is not to be construed as supervision
m) Protocols for prescriptive authority filed with DOH
n) Unlicensed midwives who practice independently of physicians are allowed to practice (ACNM)
z) May prescribe, dispense, administer
DELAWARE:
a) APN title protection only
m) Name of collaborating physician on application for licensure
n) Traditional midwives practice under a special waiver of the regulation (ACNM)
r) Initiating referrals in definition of scope
z) Prescribing medications and treatments independently - can dispense
^) A copy of the collaborative agreement must be submitted to the Joint Practice Committee
DISTRICT OF COLUMBIA:
n) Persons previously licensed under now deleted provisions may continue to practice, other "midwives unregulated but legal" (ACNM)
t) Managed care system
z) No refills on controlled substances
FLORIDA:
a) ARNP title only
b) Certified
d) Joint Practice Committee BON with BOM with two APN members
g) Included in list of options in rules for certification
h) For initial certification only
I) Limited practice in licensed midwifery
j) Supervision with protocols, collaborative language
n) Council of Licensed Midwifery regulates practice of other midwives since 1992 (ACNM)
u) Any Willing Provider law
z) Dispensing allowed but special application for privilege is required
$) RN requirement
GEORGIA:
b) Authorization to practice
g) Effective 1/1/99
j) SOP collaborative, prescriptive authority is supervisory and delegatory
p) Hospitals must provide due process rights to licensed medical professionals
u) Georgia has an Any Willing Provider law but APRNs do not seem to qualify under the definitions
z) Controlled substances and legend drugs may be prescribed and dispensed if included in protocol but location of practice, where this is allowed, is restricted to clinic and government settings
^) Written protocols define privilege, on delegated medical authority of physicians
HAWAII:
a) APRN title only
b) Recognized
d) BON but BOME involved with prescriptive authority, Department of Commerce and Consumer Affairs approves prescriptive authority
g) For prescriptive authority
h) Certification or masters
j) No particular relationship specified except for prescriptive authority
k) Not necessary if a nurse has a masters degree
m) For prescriptive authority the name of physician must be submitted
n) Midwifery practice appears to be legal (ACNM)
o) Joint and periodic evaluation
^) Prescribing, administering, dispensing and distribution of drugs
$) For prescriptive authority

REFERENCES

Main Resources

American College of Nurse Midwives, Nurse Midwifery Today, A Handbook of State Laws and Regulations 2000, Washington, DC, 2000.
Buppert C, Nurse Practitioner’s Business Practice & Legal Guide, Aspen Publications, Gaithersburg, Maryland, 1999.
Cooper RA, Multidisciplinary Healthcare Workforce Data Consortium, Meeting, April 2001, Washington, DC.
Henderson T, Chovan T , Removing Practice Barriers of NonPhysician Providers, Intergovernmental Health Policy Project, The George Washington University, February 1994.
Henderson T, Fox-Grage W, Lewis S, Scope of Practice & Reimbursement for Advanced Practice Registered Nurses, Primary Care Resource Center, Intergovernmental Health Policy Project, The George Washington University, December 1995.
Henderson T, Norris S, National Conference of State Legislators, Inc.
National Council of State Boards of Nursing, http://www.ncsbn.org.
National Council of State Boards of Nursing, The Regulation of Advanced Practice Registered Nurses 1997, Chicago, IL, 1998.
Pearson LJ. Annual Legislative Update: How Each State Stands on Legislative Issues Affecting Advanced Nursing Practice, The Nurse Practitioner 26(1):7-57.
US Department of Justice, Drug Enforcement Administration, Diversion Control Program, http://www.deadiversion.usdoj.gov/drugreg/practioners/index.html.
Washburn University School of Law, http://www.washlaw.edu
CONNECTICUT
Connecticut Department of Public Health, http://www.state.ct.us/dph
DELAWARE
State of Delaware, Delaware Administrative Code, http://www.state.de.us
DISTRICT OF COLUMBIA
Lexis Nexis, http://198.187.128.12/dc
FLORIDA
Online Sunshine, State of Florida, http://www.leg.state.fl.us
GEORGIA
State Government of Georgia, http://www.ganet.org
HAWAII
Hawaii State Legislature, http://www.capitol.hawaii.gov
Hawaii State Government, Department of Commerce and Consumer Affairs, http://www.state.hi.us