According to the Centre for Evidence-Based Medicine in Oxford, United Kingdom, evidence-based medicine is defined as, "the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients."
Nurse practitioners (NPs) and other advanced practice nurses (APNs) are held to the same high standard of care as physicians when providing healthcare services. Despite several attempts to refute widely-published research supporting safety, efficacy, and quality of care provided by APNs, heavily funded legislative and regulatory attempts to limit their authority to practice continue and may even be increasing in frequency. In an age where there is a surplus of documentation demonstrating a decline in the number of direct healthcare providers available and a need to improve access to qualified healthcare providers, it should be easier to promote the "evidence" that NPs and other APNs require less regulation in practice, not more.
Practice Barrier Battles
In 2006, 20 states successfully passed laws or drafted regulations removing practice barriers for NPs and other APNs. This report divides updates into three categories: Legal Authority, Reimbursement, and Prescriptive Authority. Information contained within the following state updates was generously provided by each state's Board of Nursing and the professional organizations responsible for, or who contribute to, the advancement of NP practice through legislative activity. This year, many exciting changes have occurred in 40% of our states; an increase of 4% over the 2005 legislative session.
Thirteen of 15 states enacted laws and regulations removing practice barriers, clarifying or standardizing educational requirements, defining advanced practice registered nurse (APRN) and primary care provider status, and clarifying global signature status. In contrast to the incredible strides of states nationwide, Alabama and Florida reported new laws and regulations restricting the practice of APRNs and other allied health professionals. One state, South Carolina, defeated legislation that would have amended the Medical Practice Act to include APRN language, which would have given the Board of Medicine (BOM) authority over APRN and RN practice. South Carolina also defeated a bill that would have restricted the use of the term "Doctor" to physicians only.
Additional Regulations
In Alabama, regulations are currently being promulgated that define "Physician's Principle Practice Site," "Remote Practice Site," "Readily Available," and "Direct Medical Intervention." Additionally, regulations are being promulgated regarding requirements for collaborative practice pertaining to physician availability for Certified Registered Nurse Practitioners and Certified Nurse Midwives in a remote practice site.
Florida passed legislation stipulating the number and type of offices a physician may supervise. Additionally, this new law, contained in the Medical Practice Act and subsequent regulations enforced by the BOM, restricts physicians who supervise Advanced Registered Nurse Practitioners (ARNPs) or Physician Assistants (PAs) in dermatology or skin care practices. "The supervising physician must be board-certified or board-eligible in dermatology or plastic surgery, and the office supervised must be within 25 miles of the physician's primary office location or in a contiguous county, but in no case further than 75 miles from the primary office location. All practices where a physician supervises an ARNP or PA other than the primary practice location must conspicuously post a current schedule of the regular hours when the physician is present in that office and the hours the practice is open when the physician is not present" (Barbara Lumpkin, RN, Assistant Executive Director, Florida Nurses Association). The Florida Nurses Association and the grassroots efforts of the ARNPs fought hard to oppose this legislation but were ultimately unsuccessful. In an era of practicing "evidence-based medicine," it would be interesting to hear how the "evidence" supported additional regulation of NPs in such a narrow practice specialty.
Reimbursement Changes
Four states reported the passage of legislation and regulation improving reimbursement for APN services. California passed legislation authorizing all certified NPs to bill Medi-Cal directly and be independently reimbursed at 100% of the physician reimbursement rate. Louisiana reported the passage of legislation requiring reimbursement of APRN services by all health plans in accordance with a collaborative practice agreement. Minnesota reported the passage of a bill authorizing a payment rate increase of 23.7% over current payment rates for psychiatrists and psychiatric/mental health APRNs. Texas passed a bill giving all healthcare practitioners a 100% tax credit, including actual expenses incurred for uncompensated care provided to indigent clients) for the amount of revenue from Medicaid, Medicare, CHIP, Tri-Care, and any other state or federally funded insurance program.
Prescriptive Authority At Last
In April 2006, Georgia became the 50th state to enact legislation authorizing prescriptive authority for APRNs. After 6 years of hard work, the association, coalition, and grassroots efforts have paid off. APRNs across the nation applaud your efforts and resolve.
In 2006, 10 states reported the passage of laws favorably impacting APN prescriptive authority. Connecticut removed site restrictions for prescriptive authority. Kentucky attained controlled substances (CS) authority, and Virginia expanded their current CS authority to include CS II medications. Nebraska and South Dakota removed restriction to CS II prescriptive authority. New Mexico, Ohio, and Oklahoma reported favorable changes in the regulations pertaining to prescriptive authority.
Finally, the findings of this survey show signs of new strategies by organized medicine to restrict the practice of physicians who collaborate with or supervise APRNs. Is this a beginning of a new trend or merely isolated anomalies? Could a response by physicians who do not want to see their practice restricted end this, if indeed it is a trend? In-depth studies are necessary to definitively answer these questions.
We congratulate all of those who have successfully improved the practice environment in their states, and we applaud the efforts of our colleagues individually and collectively who have worked to defeat unnecessary, restrictive language. Stand strong and never give up your effort and right to practice your healing art. Continue to document the research supporting safe, quality healthcare. Research supports our right to provide care to our patients.