The Legislative Process

The Legislative Process

The role of the Advanced Practice Registered Nurse Interim Study Proposal 2013-199 Presented to Joint Public Health and Welfare Committee November 25th, 2014 The health care system is changing A number of barriers prevent nurses from being able to respond effectively to rapidly changing health care settings and an evolving health care system. (IOM, 2010) So must current state laws and regulatory rules The power to improve the current regulatory, business, and organizational conditions does not rest solely with nurses... Government, businesses, health care organizations,

professional associations, and the insurance industry all must play a role. (IOM, 2010) Pressures on Arkansas Healthcare AR Center for Health Improvement study (ACHI, 2012) showed 15% fewer primary care physicians than are currently needed Projected a shortage of 1000 primary care physicians within 5 years HRSA (2014) data shows an even greater shortage, which indicates a shortage of all primary care providers Arkansas has currently only about 65% of needed primary care providers Arkansas needs more primary care Source: Bureau of Clinician Recruitment and Service, Health Resources and Services providers

Administration (HRSA), U.S. Department of Health & Human Services, HRSA Data Warehouse: Designated Health Professional Shortage Areas Statistics, as of April Rural Arkansans Most at Risk Approximately 40% of the states population live in rural areas. 2011- UAMS Center for Rural Health: 514 vacancies for primary care physicians 2017 - Expected to reach 860 vacancies NPs more likely to practice in rural areas (AANP, 2013) Nationally, 18% of NPs practice in communities of less than 25,000

Arkansas Demographics In 2014, Arkansas - 75 total primary care Health Professional Shortage Areas (HPSA) designations Thirty-six entire Arkansas counties are designated as primary care HPSAs, representing almost half of the counties in the state In 61 of 75 counties in Arkansas demand for primary care exceeds supply of health care providers Most severe in 5 counties were demand outpaces supply by 75% to 85%

How can the APRN help? By improving access to care through APRN clinics By recognition of APRNs as Primary Care Providers By leading a Patient Centered Medical Home. By authorizing qualified APRNs to prescribe Schedule II controlled substances By parity in third party reimbursement By authorizing APRN hospital admitting privileges Educational Preparation APRNs already have RN preparation prior to starting advanced practice education Minimum education is a masters degree. Many pursue doctoral degrees.

NP education is competency-based; not time- based. Percentages of APRNs in Arkansas CNM; 1.18% CNS; 5.77% CRNA; 29.80% CNP; 63.26% There are 2,376 APRNs in Arkansas Certified Nurse Practitioners (CNP) 1503 CNPs Certified Registered Nurse Anesthetist (CRNA) 708 CRNAs

Certified Nurse Midwife (CNM) 28 CNMs Clinical Nurse Specialist (CNS) 137 CNS (Arkansas State Board of Nursing, 2013) Clinical Outcomes Head-to-head comparison of educational models is not the appropriate measure of clinical success or patient safety. The appropriate measure is patient outcomes. Forty years of patient outcomes and clinical research demonstrates that APRNs consistently provide high-quality and safe care.

Improving Access to Care The APRN can: Improve access to care: In rural areas In other healthcare provider shortage areas Augment the healthcare workforce Reduce delay of care Coordinate care, creating a more effective delivery model Reduce cost by decreasing duplication and repetition APRNs as a Primary Care Provider APRNS could directly provide care without physician

referral. Patients in underserved areas could see APRNs who may be much closer to where they live. Lack of PCP recognition for APRNs adds cost and inconvenience for patients without adding to quality or safety. Leading in a Patient Centered Medical Home model Center for Medicare and Medicaid (CMS) through the Comprehensive Primary Care Initiative (CPCI) define a primary care practitioner as: a physician OR nurse practitioner clinical nurse specialist

physician assistant CMS through CPCI recognizes APRNs as a team leader of the PCMH, as does the National Committee for Quality Assurance (NCQA). Arkansas VA system also recognizes APRNs as team leaders in the PCMH model Arkansas. Arkansas VA PCMH model The VAs patient-centered medical home model was launched in April of 2010 to: increase access and clinical effectiveness by identifying and removing barriers to high-quality care Patient centered care, increased access, and

care coordination are the main principles of the model referred to as: Patient Aligned Care Team or PACT VA APRN led PACT What does a PACT do? Provides total primary care and comprehensive womens health care Each PACT serves about 950-1600 patients Team members: APRN team leader, RN, LPN, and unit clerk Awards for high performing PACT teams, 2012 Fayetteville Silver Medal North Little Rock Gold Medal

VA PACT teams led by APRNs Central AR VA system Mountain Home 3 APRNs with panel sizes of ~600 to 1000 Mena 2 APRNs with panel sizes of ~850 El Dorado 1 APRN with panel size of ~500 Hot Springs 2 APRNs with panel sizes of ~1550 Searcy 1 APRN with panel size of ~1300 NLR/LR 2 APRNs with panel size of ~800

Northwest AR VA system VISN 16/Fayetteville total of 7 APRNs in PACTs 4 floats APRNs in Primary Care 1 Primary Care/HomeBased Primary Care 1 Womens Health Primary Care 1 Primary Care

. APRNS and Schedule II APRNs in 43 states may prescribe schedule II controlled drugs. Arkansas is NOT one of those. Since 1995 Arkansas State Board of Nursing as disciplined under 5 APRNs for over prescribing hydrocodone drugs. APRNs are educationally prepared to prescribe for patients with legitimate need for this drug class. Prescriptive Authority for Qualified APRNs In Arkansas: 20 year history of APRNs prescribing: APRNs have been prescribing scheduled III V medications with a good safety record. Federal DEA guidelines changed in October, moving some medications from schedule III to schedule II, making them unavailable for APRNs to prescribe in

Arkansas. We need to change Arkansas law to reflect contemporary practice needs. Six Aims of Quality Health Care (IOM, 2001): timely, patient-centered, effective, safe, efficient, & equitable Interrupt process and find another prescriber Work around of electronic record Involving 2nd provider who

may not know the patient Delay of care Increases risk of errors Disrupts continuity Not safe or efficient Not equitable or patient

centered Not timely; less effective APRNs and Schedule II prescribing Patient population Terminally ill/hospitalized with moderate to severe pain control needs APRN role in providing care Providing palliative care/ hospice care/post op care/inpatient Acutely injured; Severe

acute pain control Acute care pain control Children and adolescents with ADHD Stimulants are still in emergent/urgent care mainstay of treatment The PCMH concept coincides with the strengths of the APRN Coordination of care and patient follow-up Patient teaching and communication Management of chronic disease A whole-person orientation, focusing on

prevention Reimbursement Parity Amend Insurance statue 23-79-114 to include the APRN with prescriptive authority. The APRN is entitled to payment or reimbursement for health services on an equal basis for the services when: The health service is provided by an APRN with prescriptive authority Practicing within his or her area of competence Reimbursement Parity Lack of direct payment or low payment rates .. discourages many APRNs from establishing new clinics;

particularly given high overhead and costs associated with investments in electronic health records and other fixed costs Business costs are largely the same whether provided by physician or an APRN THIS CREATES A BARRIER TO ACCESS TO CARE Hospital admitting privileges In Arkansas, there is no federal or state statute which prevents hospital privileges for APRNs. Qualified APRNs are already being credentialed in Arkansas hospitals as hospitalists. The VA system specifically includes hospital admitting privileges for APRNs.

Who agrees The Federal Trade Commission. Relative to primary care physicians, APRNs are more likely to practice in underserved areas and care for large numbers of minority patients, Medicaid beneficiaries and uninsured patients. (FTC, 2014) Additional scope of practice restrictions, such as physician supervision requirements, may hamper APRNs ability to provide primary care services that are well within the scope of their educations and training. (FTC, 2014) Based on our extensive knowledge of health care markets, economic principles, and competitions theory, we {conclude}: expanded APRN scope of practice is good for competition and American consumers. (FTC, 2014) And

By using non-physician primary care providers to the fullest extent of the education. States can potentially work toward meeting growing healthcare needs of their rural populations National Conference of State Legislatures. (2013) Expanded utilization of NPs has the potential to increase access to health care, particularly in historically underserved areas National Governors Association. (2012) Now is the time to eliminate the outdated regulations and organizational and cultural barriers that limit the ability of nurses to practice to the full extent of their education, training and competence Institutes of Medicine. (2010)

And. NCQA Patient-Centered Medical Home Recognition is the most widely-used way to transform all clinician lead, primary care practices into medical homes. National Centers Quality Assurance (2014) States should amend current scope of practice laws and regulations to allow APRNs to perform duties for which they have been educated and certified. AARP. (2014) Supporting Opinions Federal Trade Commission (2014) well-intentioned laws and regulations may impose

unnecessary, unintended or overbroad restrictions on competition, thereby depriving healthcare consumers of the benefits of vigorous competition. United State Supreme Court. (2014) Abuses happen when professions exploit licensing laws to augment their interest while claiming to speak with the regulatory power of the state. References: Patient Centered Medical Home American Association of Family Physicians, American Academy of Pediatrics, American College of Physicians, and American Osteopoathic Association (2011, Feb.). Guidelines for patient-centered medical home (PCMH) recognition and accreditation programs. Position paper. Authors. Auerbach, D., Chen, P., Friedberg, M., Reid, R., Lau, C., Buerhaus, P., & Mehrotra, A. (2013). Nursemanaged health centers and patient-centered medical homes could mitigate expected primary care physician shortage. Health Affairs, 32(11), 1933-1941. doi: 10.1377/hlthaff.2013.0596 Beaulieu, D. (2011, Mar. 30). Nurse practitioners are becoming a foundation of medical homes. Fierce Practice Management. http://www.fiercepracticemanagement.com/story/nurse-practitioners-becoming-foundation-medical-hom

es/2011-03-30#ixzz1SVOUQPoC Berryman, S., Palmer, S., Kohl, J., & Parham, J. (2013). Medical home model of patient-centered health care. MedSurg Nursing, 22(3), 166-172. Carver, M.C. & Jessie, A. T. (2011). Patient-centered care in a medical home: An exemplar: Promoting patient-centered care in a medical home. The Online Journal of Issues in Nursing, 16(2). Klein, S. (2011, Sept.). The Veterans Health Administration: Implementing patient centered medical homes in the nations largest integrated delivery system. In: Case Study: High-performing healthcare organization. The Commonwealth Fund pub. 1537, vol. 16. Kuntz, J. (2011). Deadly spin on nurse practitioner practice. Journal of the American Academy of Nurse Practitioners vol. 23 pp. 573576. Naylor, M. and Kurtzman, E. (2010). The role of nurse practitioners in reinventing primary care. Health Affairs, 29, (5) pp. 893-899. Poghosyan, L., Lucero, R., Rauch, L. & Berkowitz, B. (2012 Sept.-Oct). Nurse Practitioner Workforce: A Substantial Supply of Primary Care Providers. NURSING ECONOMIC$, 30 (5), pp. 268-274; 294. References: Robert Wood Johnson Foundation (2013, June). Improving patient access to high-quality Care: How to fully utilize the skills, knowledge, and experience of advanced practice registered nurses. In: Charting

nursings future: Reports on Policies that can transform patient care. Stowkowski, L. (2012, Oct 9). Nurse practitioners & medical home: A natural fit. Medscape Nurses. https://drive.google.com/?tab=mo&authuser=0#folders/0B3N5Nr9PE5qHd2ktWUpPYzlGd1E Hospital Privileges Brassard, A. & Smolenski, M. (2011). AARP Public Policy Institute. Removing barriers to advanced practice registered nurse: Hospital privileges. Insight on the Issues 55, September, 2011. Department of Veterans Affairs, Offices of Nursing Services Document. APRN Independent Practice Initiative (2012). https://www.asahq.org/For-Members/Advocacy/Federal-Legislative-and-Regulatory-Activities/VHA-NursingHandbook.aspx Federal Trade Commission (2014). Policy perspectives: Competition and the regulation of advanced practice nurses. IOM (2010). The Future of Nursing: Leading change, advancing health. Phillips, S. (2014). Progress for APRN authority. The Nurse Practitioner, 39 (1), 29-52

National Governors Association (2012). The Role of Nurse Practitioners in Meeting Increasing Demand for Primary Care. Stanik-Hutt, et al., (2013). The quality and effectiveness of care provided by nurse practitioners. JNP, 9(8), 492-500 e13 References: Schedule II Medication Prescribing APRN Consensus Work Group & APRN Advisory Committee of the National Council of State Boards of Nursing. (2008, July 7). Consensus model for APRN regulation: Licensure, accreditation, certification & education. Retrieved from: http://www.aacn.nche.edu/education-resources/APRNReport.pdf

Mid-Level Practitioners Authorization by State. (n.d.). Retrieved from http://www.deadiversion.usdoj.gov/drugreg/practioners/ National Institute for Health and Clinical Excellence. (2008, September). Attention deficit hyperactivity disorder: Diagnosis and management of ADHD in children, young people and adults. Retrieved from: http://www.nice.org.uk/guidance/cg72/resources/guidance-attention-deficit-hyperacti vity-disorder-pdf \ The Florida Senate. (2008, October). Interim report 2009-117: Authorization for advanced registered nurse practitioners to prescribe controlled substances. Retrieved from http://www.floridanurse.org/arnpcorner/ARNPDocs/InterimReportPrescribingControl ledSubstances.pdf References:

Full Practice Authority DesRoches, C., Gaudet, J., Perloff, J., Donelan, K., Iezzoni, L., & Buerhaus, P. (2013). Using Medicare data to assess nurse practitioner-provided care. Nursing Outlook, 61(6), 400-407. doi:10.1016/j.outlook.2013.05.005 Everett, C. M., Schumacher, J. R., Wright, A., & Smith, M. A. (2009). Physician assistants and nurse practitioners as a usual source of care. The Journal of Rural Health, 25(4), 407-414. doi:10.1111/j.1748-0361.2009.00252.x Kuo, Y., Loresto, F., Rounds, L., & Goodwin, J. (2013). States with the least restrictive regulations experienced the largest increase in patients seen by nurse practitioners. Health Affairs (Project Hope), 32(7), 1236-1243. doi:10.1377/hlthaff.2013.0072 Laurant, M., Reeves, D., Hermens, R., Braspenning, J., Grol, R., & Sibbald, B. (2005). Substitution of doctors by nurses in primary care. The Cochrane Database of Systematic Reviews, (2), CD001271. (NOTE: Updated 2014). Moran, K. (2014). Developing the scholarly project. In K. Moran, R. Burson, & D.

Conrad (Eds.), The doctor of nursing practice scholarly project, pp. 113-140. Burlington, MA: Jones & Bartlett Learning. National Governors Association. (2012). The role of nurse practitioners in meeting increasing demand for primary care. Retrieved from http:// www.nga.org/cms/home/nga-center-for-best-practices/center-publications/page-healthpublications/col2-content/main-content-list/the-role-of-nurse-practitioners.html References: Naylor, M., & Kurtzman, E. (2010). The role of nurse practitioners in reinventing primary care. Health Affairs (Project Hope), 29(5), 893-899. doi:10.1377/hlthaff.2010.0440 Newhouse, R., Stanik-Hutt, J., White, K., Johantgen, M., Bass, E., Zangaro, G., & ... Weiner, J. (2011). Advanced practice nurse outcomes 1990-2008: a systematic review. Nursing Economic$, 29(5), 230-250. Oliver, G., Pennington, L., Revelle, S., & Rantz, M. (2014). Impact of nurse practitioners on health outcomes of Medicare and Medicaid patients. Nursing Outlook. Rigolosi, R., & Salmond, S. (2014). The journey to independent nurse practitioner practice. Journal of the American Association of Nurse

Practitioners. doi: 10.1002/2327-6924.12130 Stanik-Hutt, J., Newhouse, R. P., White, K. M., Johantgen, M., Bass, E. B., Zangaro, G., & ... Weiner, J. P. (2013). The Quality and Effectiveness of Care Provided by Nurse Practitioners. Journal for Nurse Practitioners, 9(8), 492500. doi:10.1016/j.nurpra.2013.07.004 Stillwell, S. B., Fineout-Overholt, E., Melnyk, B.M., & Williamson, K. M. (2010). Evidence-based practice, step by step: searching for the evidence. American Journal of Nursing, 110(5):41-47. References: Medicaid Reimbursement & Primary Care Provider Status for APRNs American College of Physicians. (2008).How is aShortage of Primary Care Physicians Affecting the Quality and Cost of MedicalCare?: A Comprehensive Evidence Review. Philadelphia,PA American Association of Nurse Practitioners (2014). Increase Access to Primary Care Services for Medicaid Patients. Retrieved from American Association of Nurse Practitioners (2013). Fact Sheet: Medicaid Managed Care (October, 2013). Arkansas Bureau of Legislative Research. (2008). Advanced Practice Nursing Interim Study Proposal.

Retrieved from http://www.arkleg.state.ar.us/bureau/research/Publications/Health%20Care/Advanced%20Practice%20N ursing%20Report%20-%20Project%20%2008-286.pdf . Arkansas Department of Human Services (2013). Arkansas Medicaid Program Overview. Arkansas Department of Human Services (2012). HEDIS 2012. Arkansas Nurses Association (2011). Recognition of Advanced Practice Nurses as Medicaid Primary Care Providers with equitable reimbursement. Arkansas Nurses Association Policy Brief, September. Coddington, J., Sands, L., Edwards, N., Kirkpatrick, J., & Chen, S.( 2011). Quality of health care provided at a pediatric nurse-managed clinic. Journal of the American Academy of Nurse Practitioners, 23, 674-680 Commission on a High Performance Health System. (2009). The Path to a High Performance US Health System: Technical Documentation. The Path to a High Performance US Health System: A 2020 Vision and the Policies to Pave the Way, 105(February). Retrieved from

http://www.lewin.com/content/publications/4010.pdf References: Congressional Budget Office. (1979). Physician Extenders: Their current and future role in medical care delivery. Washington, DC. Graham, R., Roberts, R. G., Ostergaard, D. J., Kahn, N. B., Jr, Pugno, P. A., & Green, L. A. (2002). Family Practice in the United States: A Status Report. JAMA, 288(9), 1097-1101. Health Resources and Services Administration. (2006). Physician Supply and Demand: Projection to 2020. Retrieved from ftp://ftp.hrsa.gov/bhpr/workforce/PhysicianForecastingPaperfinal.pdf. Kaiser Commission on Medicaid and the Uninsured (2011). Improving Access to Adult Primary Care in Medicaid: Exploring the Potential Role of Nurse Practitioners and Physician Assistants. The Henry J. Kaiser Family Foundation. Ku, L., Jones, K., Shin, P. & Hayes, K. (2011). The states next challenge Securing primary care for expanded Medicaid populations. New England Journal of Medicine, 364(6), 493 495. Mundinger, M. O. (2002). Twenty-first-century Primary Care: New Partnerships between Nurses and Doctors. Academic Medicine, 77(8), 776-780

Pew Health Professions Commission. (1994). Nurse Practitioners: Doubling the Graduates by the Year 2000. San Francisco: University of California, Center for the Health Professions. Safriet, B. (1998). Still spending dollars, still searching for sense: advanced practice nursing in an era of regulatory and economic turmoil. Advanced Practice Nursing Quarterly, 4(3), 24-33. References: State Nurse Practice Acts and Administration Rules. (2014). American Association of Nurse Practitioners. Steinwald, A. B. (2008). Primary Care Professional: Recent Supply Trends, Projections and Valuation of Services. Retrieved from http://www.gao.gov/new.items/d08472t.pdf . Yee, T., Boukus, E., Cross, D. & Samuel, D. (2013). Primary Care Workforce Shortages: Nurse Practitioner Scope-of-Practice Laws and Payment Policies. Research Brief, 13, National Institute for Health Care Reform. Centers for Studying Health System Change. Reimbursement Parity

Federal Trade Commission. (2014). Policy Perspectives: Competition and the Regulation of Advanced Practice Nurses. Retrieved from: www.ftc.gov/system/files/documents/reports/policy-perspectivescompetition-regulation-advanced-practice- nurses/140307aprnpolicypaper.pdf Oregon - NP and PA Equal Pay Webinar: Implementing HB 2902 retrieved from https://olis.leg.state.or.us/liz/2013R1/Downloads/MeasureDocument/ HB2902/Enrolled on 10/25/14 American Nurses Association, (2011). Advanced Practice Nursing: A new age in health care. American Nurses Association Backgrounder. Retrieved on 10/25/14 at https://drive.google.com/folderview?id=0B3N5Nr9PE5qHX0ZRZTJHdS1 5Vkk&usp= sharing_eid&tid =0B3N5Nr9PE5qHRHlScnpfU21vY0U Health Policy Brief: Nurse Practitioners and Primary Care," Health Affairs, October 25, 2012. References: Gavil, A., (2014). FTC Testifies on How Professional Licensing and Regulation

Can Affect Competition to the House Committee on Small Business. Federal Trade Commission Committee on Small Business, FTCs Office of Policy. Wood, Debra, 2013. MedPAC Discusses Reimbursement Equality for NPs and Pas. AMN Healthcare, Inc. Hawryluk, M. (2012). Oregon debates payment parity. The Bulletin: Published Daily in Bend Oregon by Western Communications, Inc. 2011. Yee, T., Boukus, E., Cross, D., Samuel, D. (2013). Primary care workforce shortages: nurse practitioner scope-of-practice laws and payment policies. National Institute for Healthcare Reform, Policy Brief, Number 13. The National Institute for Health Care Reform (NIHCR), Washington, DC. Darling, K. (2014). Arkansas State Representative of the American Association

of Nurse Practitioners. Spitzer, O., Sackett, D., Sibley, J., et. al., (1974). The Burlington Randomized Trial of the Nurse Practitioner. New England Journal of Medicine 1974; 290:251-256 January 31, 1974 I: 10.1056/NEJM197401312900506 For more information, please contact Rhonda Finnie, DNP, APRN, AGACNP-BC, RNFA President, Arkansas Nurses Association Mary Garnica, DNP, APRN, FNP-BC, MPH Health Policy Chair, Arkansas Nurses Association

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