PERD Application - West Virginia Nurses Association

Transcription

May 31, 2013
John Sylvia, Director
Performance Evaluation & Research Division
State Capitol Complex Building 1, Room 314W
Charleston, West Virginia 25305
Dear Performance Evaluation and Research Division Members,
The West Virginia Nurses Association (WVNA) in conjunction with nurse leaders in West
Virginia and the United States has researched and written the attached Sunrise application for
your review. The focus of this document is section B of the application - justifying a revision or
expansion of a scope of practice within an existing profession.
This application specifically addresses the professional practice of Advanced Practice Registered
Nurses (APRNs) in WV. The 2012/13 updates in the code define APRNs in WV to include:
Nurse Practitioners, Certified Nurse Midwives, and Certified Registered Nurse Anesthetists as
well as Clinical Nurse Specialists.
APRNs are licensed independent practitioners who are expected to practice within
established standards recognized by a licensing body. Each APRN is accountable to patients, the
nursing profession, and the licensing board to comply with the requirements of the state nurse
practice act and the quality of advanced nursing care rendered; for recognizing limits of
knowledge and experience, planning for the management of situations beyond the APRN’s
expertise; and for consulting with or referring patients to other health care providers as
appropriate. (Consensus Model for APRN Regulation: Licensure, Accreditation, Certification &
Education, July 7, 2008, APRN Consensus Work Group & the National Council of State Boards
of Nursing APRN Advisory Committee).
Therefore, it is important to note that none of the requested changes to WV code for APRNs
allows any practice outside the current professional educational scope and standards for APRNs.
The APRNs of WV are proposing a retirement of outdated codes and regulations that limit
practitioners from practicing to their full scope which results in decreased access to care West
Virginian citizens.
We further emphasize that standards for all healthcare professionals never recommend practice at
any level without collaboration and consultations with other healthcare professionals. This
application is simply a retirement of the outdated barriers in the written, legally liable, time
intensive and cost prohibited collaborative regulatory statute.
In summary, three barriers this application addresses are:
1. Removing the written collaborative agreement regulation as mentioned above.
P O Box 1946, Charleston, WV 25327
304-342-1169
www.wvnurses.org
2. Expanding medication prescribing. Thus, allowing the APRN to prescribe and monitor
medications based on proper practice evidence. The current law is convoluted and cumbersome
and does not allow best and timely prescribing of medication to primary patients as needed to
provide the safest, high quality of care in WV. This would also allow close monitoring of
medications by the health professional providing direct care. Examples include hospice patients,
home bound patients, rural patients and primary patients.
3. Global signatures to applications and documents related to the health care of primary patients.
Examples include death certificates, DNRs, and various handicapped accessible documentations.
Thank you for your time and consideration of this application. WVNA and the APRNs of WV
look forward to working closely with the PERD members in this endeavor. Please
direct questions or concerns directly to me as your primary contact person.
I am Elizabeth Baldwin, PNP, BC, APRN chair of WVNA and the state representative for the
American Association of Nurse Practitioners.
My contact information is:
Address: Route 1 box 277, Grafton WV, 26354
Phone: 304-265-3029 (home), 304-282-8833 (cell) often best
Email: [email protected]
Additional sponsors to this application are:
Aila Accad, MSN, RN, President, West Virginia Nurses Association
Ruth Blevins, RN, Executive Director, West Virginia Nurses Association
Deborah Casdorph, MSN, FNP-C, Family Nurse Practitioner in a grant based clinic for
underserved area of West Virginia
Lena Antimonova Cerbone, CNM, MSN, Faculty WVU School of Medicine, Department
OB/GYN and Reproductive Medicine
Sandra Cotton, DNP, ANP-BC, FNAP, Director Faculty Practice, WVU School of Nursing
Toni DiChiacchio, MSN-FNP-BC, Business Owner and APRN, Health Thru Care, LLC
Mike Frame, DMP, CRNA, President, WV Association of Nurse Anesthetists
Tammy Hamilton, DNP, Family Nurse Practitioner, owner of Martinsburg Family Healthcare
Evelyn Martin, DNP, RN, APRN, FNP-BC, Vice President WVNA and Lecturer, West Virginia
University School of Nursing, Hospice APRN, and APRN of the Dept. of Corrections
Residential Substance Abuse Treatment (RSAT) program for WV State Prisoners
Angelita Nixon, CNM, LLC, home delivery midwife, WVNA treasurer
Cynthia Armstrong Persily, PhD, RN, FAAN, Associate Dean, Graduate Practice Programs,
West Virginia University School of Nursing
Cassy Taylor, DNP, DMP, CRNA, CNE, WV Association of Nurse Anesthetists
APRN Committee Chair
West Virginia Board of Examiner’s for Registered Professional Nurses, President, Robin
Walton, EdD, MSN, RN, FNP-BC
P O Box 1946, Charleston, WV 25327
304-342-1169
www.wvnurses.org
PERD APPLICATION APRN
B. For applications for a revision or expansion of a scope of practice, please respond to the
following questions in the order provided.
1. Provide a definition of the problem and why a change in scope of practice is necessary,
including the extent to which consumers need and will benefit from practitioners with
this scope of practice.
Definition of Problem: In a prepared statement by the Federal Trade Commission
(Appendix A) West Virginians are particularly vulnerable to access issues caused by
physician shortages (Federal Trade Commission, 2012). West Virginia currently suffers
from shortages of primary care providers, and these shortages are expected to increase as
more West Virginians gain health insurance and seek access to primary health care
services. Legislative action to eliminate the collaborative agreement requirement for
prescriptive authority improves access and consumer choice for primary care services,
especially for rural and other underserved populations, and encourages beneficial price
competition that could help contain health care costs.
Furthermore, according to Families USA and West Virginians for Affordable Health
Care, beginning January 2014, West Virginia will add an estimated 166,000 uninsured
low income West Virginians with Medicaid expansion (Government Accountability
Office, 2012; West Virginians for Affordable Health Care, 2012).
The Institute of Medicine (IOM), in a landmark consensus report: “The Future of
Nursing: Leading Change, Advancing Health,” details recommendations for
policymakers and others concerned with improving health care. The IOM, whose
committee members include physicians and other professionals in business, academia,
health policy and health care delivery, recommended:

State legislatures should reform scope-of-practice regulations to conform
to the National Council of State Boards of Nursing Model Nursing
Practice Act and Model Nursing Administrative Rules;

Congress should expand the Medicare program to cover services provided
by APRNs within their scope of practice just as physicians are currently
covered

The Federal Trade Commission and Antitrust Division of the Department
of Justice should review existing and proposed regulations affecting
APRNs to ascertain those with anticompetitive effects without
contributing to health and safety.
West Virginia’s current statutes have outdated restrictions on advanced practice
registered nurses (APRNs). These laws, written over 20 years ago, prevent APRNs from
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practicing to the full extent of their education and training. Because health care is an
evolving, dynamic system, changes in regulated scope of practice are inherent in health
care delivery (Beach, 2012).
Current WV APRN statute defines an APRN as “(a) …a registered nurse who has
acquired advanced clinical knowledge and skills preparing him or her to provide direct
and indirect care to patients, who has completed a board-approved graduate-level
education program and who has passed a board-approved national certification
examination. An advanced practice registered nurse shall meet all the requirements set
forth by the board by rule for an advanced practice registered nurse which shall include,
at a minimum, a valid license to practice as a certified registered nurse anesthetist, a
certified nurse midwife, a clinical nurse specialist or a certified nurse practitioner.” (§307-1 et seq.; §19-7-2). There are varied practice restrictions among APRNs including a
requirement for a written “collaborative agreement” to prescribe medications (§30-7-1 et
seq., §19-7-1 et seq., and §19-8-et seq.)
Sixteen states and the District of Columbia currently allow full practice authority (FPA)
for APRNs (National Council of State Boards of Nursing, 2012). While these states have
kept pace, some, including WV, lag behind in allowing APRNs to see patients and
prescribe medications without a physician’s supervision or collaboration. The Institute of
Medicine’s (IOM), comprised of physicians, and other professionals in business,
academia, and health policy, have reported that upon graduation “what NPs are able to do
varies widely for reasons that are related not to their ability, education or training, nor to
safety concerns, but to the political decisions of the state in which they work.” (Institute
of Medicine, 2010).
In WV there is a disconnection between the high level of care APRNs are capable of
providing and the limited level of care the current law allows them to deliver. Closing the
gap between clinical education and training and regulated practice may help end some of
the disparities that patients encounter when they seek healthcare and improve the quality
and efficiency of care by eliminating the costs associated with dated, bureaucratic
requirements that do nothing to enhance safety or quality (American Association of
Retired People, 2011).
Why a Change in Practice is Necessary: Primary Care Dilemma in West Virginia
Jennifer Fellman (2012) composed a white paper on APRNs in West Virginia as part of
her doctoral education which included the following facts regarding health care in West
Virginia:
Rural areas have notoriously lacked adequate access to primary care physicians to
meet the needs of their residents. Appalachia, including West Virginia, is
traditionally known to suffer from significant economic challenges and
insufficient health care. This region faces continued physician shortages due to its
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rugged, vast geography. Some 42% of Appalachian residents reside in rural
locales, further complicating access to primary care providers (Baker et al, 2012).
In 2011, just under half of the total population, 10,819,192 people, resided in a
rural area in West Virginia (United States Department of Agriculture (2012).
According to the Health Resources and Services Administration (2012), West
Virginia has 53 designated medically underserved geographical areas (Figure 1)
and has 89 designated primary care Health Professional Shortage Areas (HPSAs)
(Appendix B) impacting 120,465 or nearly 6% of WV citizens. In addition to
socioeconomic barriers to care, providers that are unwilling to accept patients
with Medicare/Medicaid contribute to West Virginia’s HPSAs (2012).
Figure 1 Medically Underserved Areas and Medically Underserved
Populations. Retrieved from Rural Assistance Center (2012).
http://www.raconline.org/racmaps/mapfiles/mua_muptype.png.11
Chronic disease is the leading cause of death for West Virginians. A 2011 report
from the West Virginia Department of Health and Human Resources found that
West Virginians have significantly higher rates than the rest of the nation for poor
nutrition, smoking, obesity, diabetes, hypertension, stroke, coronary heart disease,
heart attack and arthritis. Table 1 illustrates West Virginia compared to the U.S.
population regarding insurance, health care spending and poverty rates:
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Table 1 Data retrieved from Kaiser Family Foundation (2009).
http://www.statehealthfacts.org/profile.jsp?ind
According to the “State Scorecard” published by the Commonwealth Fund
(2012), West Virginia ranks poorly for several criterion. Ranking is from 1st to
50th.
For 2009 West Virginia scored:
 50th for healthy lives (breast and colorectal cancer deaths,
suicide, tobacco use, child obesity, infant mortality)
 47th for avoidable use of hospital care
 27th for overall access to health care services.
In order to improve access to care and to prevent unnecessary hospital
admissions, the Commonwealth Fund recommends a relationship with a primary
care provider who can coordinate care. If West Virginia was to match the best
performing state for each criterion:
 $41 million dollars would be saved from hospital readmissions
 $71 million could be saved from overall hospitalizations
 71,000 adult citizens would receive recommended preventive care
(colonoscopy, mammogram, flu shots)
 144,000 West Virginia adults would have a source of reliable care
so that their health needs are coordinated and accessible
(Commonwealth Fund, 2012).
Infant mortality rate is another measure of the nation’s health and is measured as
deaths per 1,000 live births. West Virginia’s overall infant mortality rate (Figure
2) is 7.7 compared to 6.9 for the rest of the United States. Thirty-six counties in
West Virginia have an infant mortality rate higher than the U.S. average, and 2
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counties had a rate more than twice the national average. Less than U.S. rate (6.9)
6.9 to 13.8 More than twice the U.S. rate (13.9+) Source: NCHS Natality and
Mortality Detail Files Data access from the Area Resource File Health Resources
and Services Administration, HHS. Increasing costs of medical liability insurance
for providers performing obstetric care, a decline in the number of hospital and
birthing facilities, and the lack of obstetricians practicing in rural locales
contributes to inadequate access and timely prenatal care for West Virginian
women (Appendix C). Clearly change is needed to improve West Virginia’s
maternal-child health outcomes.
Figure 2 Infant mortality rates, 5--‐year average From 2000--‐2004. 12
National Trends
Source: NCHS Natality and Mortality Detail Files Data access from the Area
Resource File Health Resources and Services Administration, HHS.
According to The National Governor’s Association White Paper entitled “The Role of
Nurse Practitioners in Meeting Increasing Demands for Primary Care Services” Primary
Care and Health Care Reform: The aging and growth of the U.S. population, along with
the health care coverage expansions and other initiatives under the ACA, is expected to
significantly increase demand for primary care services in the coming years.
Since the passage of the ACA in 2010, more than two million Americans have been
added to health insurance rolls. The total number of people expected to gain health
insurance had been expected to increase to 30 million by the year 2016, but states were
given flexibility about whether to expand (or not expand) their Medicaid programs by the
U.S. Supreme Court’s June 2012 decision upholding the ACA overall. For that reason, it
is now unclear what the full extent of the insurance expansion under the ACA will be.
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However, regardless of each state’s decision regarding expansion of Medicaid, there will
be increased coverage stemming from the 16 million people who are eligible to obtain
new subsidies for private coverage offered through the health insurance exchanges
authorized by the ACA, as well as by the ACA’s mandate for most individuals to carry
health insurance (National Governor's Association, 2012).
Beyond expanding health insurance coverage, the ACA provides new incentives for
enrollees in public and private health insurance plans to seek preventive health care
services by eliminating patient cost-sharing. Insurers will be required to cover—without
patient cost-sharing—a number of preventive services the U.S. Preventive Services Task
Force recommends, as well as additional services specifically recommended for women
and children which, even if considered alone, would create a substantial increase in
demand for primary care (National Governor's Association, 2012)
One study projects that by the year 2019, the demand for primary care in the United
States will increase by between 15 million and 25 million visits per year, requiring
between 4,000 and 7,000 more physicians to meet this new demand.4 Moreover, any
increased demand for primary care will be added to an already existing shortage of
primary care practitioners. The federal Health Resources and Services Administration
(HRSA) estimates that more than 35.2 million people living within the 5,870 Health
Professional Shortage Areas (HPSAs) nationwide do not currently receive adequate
primary care services (National Governor's Association, 2012).
Several barriers impede nurses’ ability to respond efficiently to a rapidly evolving health
care system. The current barriers APRNs face in providing care to WV residents include,
but are not limited to, the written collaborative regulatory requirements, restrictions on
medication prescribing, loss of autonomy, and the inability to sign certain healthcare
documentation for patients currently under their care. Modernizing the current regulatory
requirements via retirement of these barriers is a necessary change to allow APRNs to
provide timely, high quality, cost effective, and patient-centered care.

Loss of autonomy: Autonomous practice is within the recognized APRN scope of
practice in all four roles (CNM, CRNA, NP, and CNS). Masters or doctoral degrees
are currently required for APRN entry to practice and national certification. Many
states already recognize APRNs as autonomous professionals. However, in WV this
independent autonomy is not fully supported by policy.

The collaborative agreement: The existing WV law requires each APRN to maintain a
written collaborative agreement with a physician in order to write prescriptions. Even
though physicians are not responsible for the prescribing practice, do not supervise
the APRN, and are not responsible for the APRN’s patients, some physicians have
expressed unfounded concerns that collaborating with an APRN may place them at
higher risk for vicarious liability. As a result, physicians often refuse to sign these
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agreements, thus reducing the number of APRNs who are able to practice in WV.
This is an illogical and unnecessary burden on the health care system.

In addition, the WVBOM has established a set of minimum requirements and
additional burdensome guidelines that may further confuse and alienate professional
relationships between physicians and nurse practitioners. These guidelines are labeled
as “helpful, common sense suggestions” but have no evidence-based grounding.

Restricted drug classes: WV’s current law restricts the kind and amount of
medications the APRN may prescribe. For example, rheumatoid arthritis therapies,
pain medications, and certain endocrine treatments which are common primary care
prescriptive interventions for APRNs, are restricted. Close monitoring of these
conditions and medications are integral in APRN care.

Ability to sign documents related to care. Whenever any law or regulation requires a
signature, certification, stamp, verification, affidavit, or endorsement by a physician,
it is important that it also be deemed to include a signature, certification, stamp,
verification, affidavit or endorsement by a nurse practitioner. However, current WV
law does not consistently support the APRNs ability to sign health related documents,
such as death certificates, Do Not Resuscitate Orders, or certain Handicap Supportive
Services.
How Consumers Need and Will Benefit: Consumers stand to benefit from these
changes by improved access to health care, improved health outcomes in certain chronic
diseases, and the potential for controlled health care costs (American Association of
Retired People, 2011). Additionally, receiving primary care that, rather than focusing on
the management of acute episodic illness, emphasizes health education, wellness,
prevention and screening for early detection of disease will benefit WV residents.
Mounting evidence and support for modernizing the WV State Nurse Practice Act cited
in a letter from the American Academy of Nurse Practitioners president (Golden, 2012)
includes:
 APRNs have been providing safe, high quality care for nearly half a century.
 In over 100 studies that span more than 40 years without exceptions, all studies
found that APRNs and physicians provide equivalent care in regards to safety. In
fact, these studies have shown NPs have the same or better patient outcomes when
compared to physicians.
 Over 80% of APRNs are prepared in primary care and 18% of all APRNs practice
in rural areas.
 States with regulation that provide for the full use of APRNs under the regulation
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
of the board of nursing see an even higher percentage of rural located APRNs.
APRNs are cost effective. Multiple studies have reported on the cost effectiveness
of APRNs. One of the largest published by the JAMA in 2000 compared the care
and the resource utilization of APRNs and physicians for the care of 1316
randomly assigned patients at six and 12 months, resource utilization and patient
health care status were the same for both groups.
In compiling The National Governor’s Association White Paper entitled “The Role of
Nurse Practitioners in Meeting Increasing Demands for Primary Care Services” Primary
Care and Health Care Reform; a thorough literature review was completed. What follows
are the findings:
Quality—Process Measures: Several studies have attempted to measure
differences in the quality of care offered by NPs and physicians. Among the
quality of care components that these studies measure are several process
measures, among them patient satisfaction, time spent with patients, prescribing
accuracy, and the provision of preventive education. In each of these categories,
NPs provided at least equal quality of care to patients as compared to physicians
(all studies cited below). NPs were found to have equal or higher patient satisfaction rates than physicians and also tended to spend more time with patients
during clinical visits. Notably, two studies showed higher patient satisfaction
among NPs, and three studies found no significant difference between patient
satisfaction among those seen by physicians and those seen by NPs.
In these studies patient satisfaction was generally measured through patient
surveys. One of the studies that showed higher patient satisfaction among NPs’
patients also asked patients about their preference for provider type. Although
patients showed no preference between a physician and an NP for nonmedical
aspects of care, patients did report a general preference for care from a physician
for medical aspects of care. Three studies showed that NPs spent more time with
patients than did physicians and one study showed no significant difference.
Several studies also attempted to compare NPs and physicians in the provision of
care according to appropriate practice standards. These studies showed that NPs
generally prescribe medications well and follow clinical care guidelines. Two
chart-review studies show no differences in the prescribing quality between NPs
and physicians. A 2009 study that tracked second opinions of Medicaid
psychotropic medication prescriptions for children found no difference between
the number of adjustments made to the prescriptions written by physicians and
those written by NPs. A 1998 study found that physician reviews of APRNs’
(including NPs) prescribing practices were generally positive. One study showed
NPs practiced greater adherence to geriatric quality care guidelines and another
study showed NPs are better able to provide preventive education through the
delivery of anticipatory guidance.
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Quality—Outcome Measures: In addition to process-related quality measures,
some of the papers identified in the literature review evaluated data on patient
care provided by NPs, reporting on quality-related outcomes as determined by
actual changes in physiological measures such as decreased cholesterol, blood
pressure, and weight. These studies conclude that NPs are capable of successfully
managing chronic conditions in patients suffering from hypertension, diabetes,
and obesity. In one study, NP participation in physician teams resulted in better
control of hypertensive patients’ cholesterol levels.
A separate study found that patients of independent NPs were better able to
achieve weight loss than the control group under traditional physician-based care.
Three studies showed that care provided by NPs resulted in reductions in patient
blood pressure readings. Patient self-reporting of overall health status was higher
among those cared for by NPs in another study. Three studies specifically
compared the quality of diabetes-related care delivered by physician/NP teams to
physicians alone, and all three found significantly better patient outcomes among
the team-treated group. Another study found no difference between provider types
in diabetes outcomes based on physiologic measures. One study found that high
quality chronic disease management was associated with the presence of an NP in
the practice.
Quality—Meta-Analyses: The results of three meta-analyses similarly support the
conclusions of this literature review related to NP care and quality measures. The
three analyses concluded that NPs rate favorably in terms of achieving patients’
compliance with recommendations, reductions in blood pressure and blood sugar,
patient satisfaction, longer consultations, and general quality of care.
Access: Very few studies that met the criteria for this literature review analyzed
issues specifically related to access to care. However, one 2003 review found that
NPs are more likely to serve underserved urban populations and rural areas and a
2009-2010 American Academy of Nurse Practitioners national sample survey
showed that roughly 18 percent of the respondents indicated that they practiced in
rural areas. Nationally, the number of NPs is projected to nearly double by 2025,
according to a recently published RAND study in which the researchers modeled
the future growth of NPs. Specifically; the study predicts that the number of
trained NPs would increase 94 percent from 128,000 in 2008 to 244,000 in 2025.
“Nurse practitioners really are becoming a growing presence, particularly in
primary care,” said David I. Auerbach, Ph.D., the author and a health economist
at RAND Corp. Auerbach also concluded that “NPs will likely fulfill a substantial
amount of future demand for care.” Auerbach’s projections are reflective of
current trends that suggest a consistently upward increase in the number of trained
and qualified NPs.
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Conclusion: In NGA’s literature review none of the studies raised concerns about
the quality of care offered by NPs. Most studies showed that NP-provided care is
comparable to physician-provided care on several process and outcome measures.
Moreover, the studies suggest that NPs may provide improved access to care.
Removing the requirement that APRNs who want to prescribe medications have a
collaborative agreement with a physician has the potential to benefit consumers by
expanding choices for patients, containing costs, and improving access. Maintaining an
unnecessary and burdensome requirement is likely to deprive consumers of the benefits
that increased competition can provide. Absent countervailing safety concerns regarding
APRN prescribing practices, removing the collaborative agreement for prescriptive
authority appears to be a procompetitive improvement in the law that would benefit West
Virginia health care consumers (Federal Trade Commission, 2012).
In summary, there are 3 barriers that this application addresses to allow APRNs to
exercise full practice scope within WV. These are:

Removing the written collaborative agreement regulation. This is simply
requesting a retirement of the outdated barriers in the written, legally liable, time
intensive and cost prohibited collaborative regulatory statute.

Expanding medication prescribing. Thus, allowing the APRN to prescribe and
monitor medications based on best practice evidence. The current law is very
convoluted and cumbersome and does not allow for appropriate and timely
prescribing of medication to primary patients as needed to provide the safest, high
quality of care in WV. This would also allow close monitoring of medications by
the health professional providing direct care. Examples include hospice patients,
home bound patients, rural patients and primary patients.

Global signatures to applications and documents related to the health care of
primary patients. Examples include death certificates, DNRs, and various
handicapped accessible documentations.
2. Provide an explanation of the extent to which the public can be confident that qualified
practitioners are competent including:
a. Evidence that the profession’s regulatory board has functioned adequately in
protecting the public.
The West Virginia Board of Examiner’s for Registered Professional Nurses (WV
RN Board) has successfully protected the public through the regulation of
registered professional nurses for over 100 years, and the separate role of the
advanced practiced registered nurses since 1992 (WV Board of Examiners for
Registered Professional Nurses, 2012). Furthermore, the Board investigates
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complaints, takes disciplinary action and evaluates credentials related to APRN’s.
In 2012, the law passed requiring a license to practice as an APRN, the related
rules passed during the 2013 Legislative Session (§30-7-1 et seq.; §19-7-1 et
seq.).
b. Whether effective quality assurance standards exist in the profession, such as
requirements associated with specific programs that define or endorse standards
or a code of ethics; and
Effective quality assurance standards exist in the profession in the following
ways:
1.
WV Code, laws, rules and guidelines (§30-7-1et seq., §30-15-1et
seq., §19-7-1 et seq., §19-8-1et seq., §19-9-1 et seq., §19-10-1et
seq., and §19-11-1et seq.);
2.
Clinical standards of practice established by the approved
certification agencies (AACN, AANP, etc.);
3.
Code of Ethics and standards established by national professional
associations, e.g., ANA, AANP, etc. (See attached ANA Code of
Ethics, Appendix D).
4.
WV State laws related to third party reimbursement;
5.
Complaint process available to the public;
6.
Education standards enforced by national accrediting agencies
(ACEN; CCNE; COA).
In addition, APRNs are licensed independent practitioners who are expected to
practice within standards established or recognized by a licensing body. Each APRN
is accountable to patients, the nursing profession, and the licensing board to comply
with the requirements of the state nurse practice act and the quality of advanced
nursing care rendered; for recognizing limits of knowledge and experience, planning
for the management of situations beyond the APRN’s expertise; and for consulting
with or referring patients to other health care providers as appropriate (National
Council of States Board of Nursing, 2008).
c. Evidence that state approved education programs provide or are willing to provide
core curriculum adequate to prepare practitioners at the proposed level.
West Virginia Board of Registered Professional Nurses response:
The advanced practice registered nurse education programs in West Virginia
provide a core curriculum adequate to prepare practitioner’s at an advanced level
by meeting the stringent requirements of a national nursing accreditation agency
(CCNE; ACEN.). These programs have been established in West Virginia for
over 20 years.
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Cynthia Armstrong Persily PhD, RN, FAAN
Associate Dean, Graduate Practice Programs (MSN and DNP)
Professor and Chairperson, Charleston Division
West Virginia University School of Nursing response:
The West Virginia University School of Nursing provides education for the
advanced practice of nursing in the functional areas of family nurse practitioner
(FNP), pediatric nurse practitioner (PNP), neonatal nurse practitioner (NNP), and
women's health nurse practitioner (WHNP). The school also offers post-graduate
family, pediatric, neonatal, and women's health nurse practitioner certification
programs for those who already have a M.S.N.
Throughout the curriculum, students are guided in the process of selfdevelopment aimed at pursuing excellence in scholarly and professional
endeavors. The program allows flexibility within the basic curricular structure
through the individualization of learning experiences and participation in a guided
research experience.
Master's education in nursing prepares clinicians and educators capable of
leadership in developing and expanding nursing knowledge, skills, and practice
competencies. Preparation at the master's level provides the opportunity for
students to demonstrate self-direction and effective interactions with other health
professionals in promoting and restoring health.
Graduates meet all requirements to sit for the national certification examination in
their specialty area of family nurse practitioner, pediatric nurse practitioner,
women’s health nurse practitioner and neonatal nurse practitioner. They are
prepared to offer care at the advanced practice level to selected populations, and
are able to perform all activities encompassed in the traditional scope of practice.
The pattern and duration of the student's study plan is determined in consultation
with a faculty advisor and is based upon the student's background and goals. The
44-credit program can be completed in two and a half years of full time study.
Completion of the program in part-time study includes six semesters and two
summer sessions or three full years. Clinical experiences total a minimum of 600
clock hours in direct patient care settings during the final year of the program.
This number exceeds requirements for national board certification.
The MSN program and curriculum is based on national standards for the
advanced practice of nursing. These standards and guidelines are:
AACN. (1996) The essentials of master’s education for advanced practice
nursing. Washington, DC: Author.
AACN. (2006). The essentials of doctoral education for advanced nursing
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practice. Washington, DC: Author. 8
American Nurses Association (2005) Code for of ethics with interpretive
statements. Washington, DC: Author.
American Nurses Association (2005). Nursing: Scope and standards of practice.
Washington, DC: Author.
National Organization of Nurse Practitioner Faculties. (2008). Criteria for the
evaluation of nurse practitioner programs. Washington, DC: Author.
U.S. Department of Health and Human Services, Health Resources and Services
Administration. (2002). Nurse practitioner primary care competencies in
specialty areas: Adult, family, gerontological, pediatric, and women’s
health. Rockville, MD: Author.
The WV Nursing code and legislative rules (§30-7-1 et seq., §30-15-1 et seq.,
§19-7-1 et seq., §19-8-1, et seq., §19-9-1 et seq., §19-10-1 et seq., and
§19-11-1 et seq.).
These professional standards and guidelines provide a strong foundation for the
development of master’s degree nursing programs that prepare graduates for
clinical and leadership roles in the current and future health care delivery systems.
In addition, the WV Nursing Code and Legislative Rules (2013) guide the
practice of all registered nurses in West Virginia and the development of nursing
curricula, clinical experiences, and education policies.
The MSN program is accredited by the Council on Collegiate Nursing Education
(CCNE). The CCNE is the sole accrediting agency that accredits only
baccalaureate and higher degree programs. Their new accrediting process was
initiated in 1998 and West Virginia University School of Nursing was in the
initial accreditation cycle. The School received a full, 10 year, accreditation for
the baccalaureate and masters' programs in April, 1999. In April 2009, the School
received another full 10 year re-accreditation for the baccalaureate and masters'
programs, with all standards met and no areas of concern. Prior to seeking CCNE
accreditation, the nursing programs at WVU had been continuously accredited by
the National League for Nursing, with the baccalaureate program receiving initial
accreditation in 1964, the year of the first graduating class, and the master's
program in 1981. The last year for National League for Nursing accreditation was
1998, and the CCNE accreditation was retroactive to Fall of 1997.
Cassandra Taylor DNP, DMP, CRNA, CNE
Instructor, CAMC School of Nurse Anesthesia,
Associate Faculty, Lewis College of Business Marshall University response:
Certified Registered Nurse Anesthetists (CRNA)
West Virginia has one nurse anesthesia educational program, the Doctor of
13
Management Practice in Nurse Anesthesia Program (DMPNA) through
Charleston Area Medical Center School of Nurse Anesthesia and Marshall
University. In 2008, the DMPNA program received a 10 year accreditation from
the Council on Accreditation of Nurse Anesthesia Educational Programs (COA)
as the first entry level nurse anesthesia doctorate program in the nation. The COA
is recognized the U.S. Department of Education (USDE) and the Council for
Higher Education Accreditation (CHEA). DMPNA graduates are eligible to take
the National Certifying Examination of the National Board of Certification &
Recertification for Nurse Anesthetists.
The DMPNA program curriculum is grounded in the goal that graduates will
become respected health care leaders capable of promoting the delivery of cost
efficient, high quality, evidence based anesthesia care to the public. The DMPNA
program design meets the standards for practice oriented doctoral degrees as
established by the COA.
The DMPNA program is a 127 semester hour, 36 month program consisting of
academic and clinical curriculum. The clinical curriculum prepares the student for
the full scope of current practice in a variety of work settings and requires a
minimum of 650 clinical cases including a variety of procedures, techniques and
specialty practice. DMPNA graduates of 2012 averaged 779 clinical cases and
1330 clinical hours.
COA accreditation standards require three separate comprehensive graduate level
courses in advanced physiology/pathophysiology, advanced health assessment
and advanced pharmacology. The DMPNA curriculum includes 7 semester hours
in advanced pharmacology.
NUR 720 – Pharmacology for Nurse Anesthesia I (4hours) examines the general
principles of pharmacology, pharmacokinetics, pharmacodynamics, and
biochemistry and their concepts as they relate to specific anesthetic and adjunct
drugs. It will emphasize integration of acquired information into clinical areas
regarding anesthetic uses, doses, and side effects of these classes of drugs.
NUR 721 – Pharmacology for Nurse Anesthesia II (3hours) This study is a
continuation of Pharmacology I. It will examine factors impacting drug selection,
focusing on interdisciplinary collaboration and economic issues in implementing
change. It will also address the acquisition and utilization of advanced practice
prescriptive authority for the nurse anesthetist. (Course Descriptions, CAMC
Institute website, found at http://camcinstitute.org/anesthesia/courses.htm
Shenandoah University Nurse-Midwifery Program administers Marshall
University and WV Wesleyan midwifery curriculum.
14
Juliana van Olphen Fehr, CNM, PhD, FACNM
Director, Nurse-Midwifery Program
Shenandoah University Nurse-Midwifery Program
Eleanor Wade Custer School of Nursing response:
Shenandoah University Nurse-Midwifery Program is approved by the
Commonwealth of Virginia and provides a curriculum that meets the Core
Competencies for Basic Midwifery Practice, 2012 for students obtaining a Master
of Science in Nursing as promulgated by the American College of NurseMidwives. The Program is accredited by the Accreditation Council for
Midwifery Education, and all graduates are eligible to take the American
Midwifery Certification Board examination to become Certified Nurse-Midwives.
The Program is also within a Commission for Collegiate Nursing Education
(CCNE) accredited Nursing School. Shenandoah University is accredited by the
Southern Association of Colleges and Schools (SACS). WV State Midwifery
programs require 45 semester hours with a grade point average of 3.0 or better.
Clinical practicum is approximately 720 clock hours. Pharmacology is
incorporated in the required clinical practicum hours.
3. Explain the extent to which a revision or expansion in the scope of practice may harm the
public:
There is no evidence that shows the proposed expansion will be harmful to the public. In
fact, extensive research demonstrates the safety and quality of APRNs including the
following information from the American Academy of Nurse Practitioners (2013):
Nurse practitioners (NPs) are high quality health care providers who practice in
primary care, ambulatory, acute care, specialty care, and long-term care. They are
registered nurses prepared with specialized advanced education and clinical
competency to provide health and medical care for diverse populations in a
variety of settings. A graduate degree is required for entry-level practice. The NP
role was created in 1965 and over 45 years of research consistently supports the
excellent outcomes and high quality of care provided by NPs. The body of
evidence supports that the quality of NP care is at least equivalent to that of
physician care. This paper provides a summary of a number of important research
reports supporting the NP.
Avorn, J., Everitt, D.E., & Baker, M.W. (1991). The neglected medical
history and therapeutic choices for abdominal pain. A nationwide study of
799 physicians and nurses. Archives of Internal Medicine, 151(4), 694-698.
A sample of 501 physicians and 298 NPs participated in a study by responding to
a hypothetical scenario regarding epigastric pain in a patient with endoscopic
findings of diffuse gastritis. They were able to request additional information
before recommending treatment. Adequate history-taking resulted in identifying
15
use of aspirin, coffee, cigarettes, and alcohol, paired with psychosocial stress.
Compared to NPs, physicians were more likely to prescribe without seeking
relevant history. NPs, in contrast, asked more questions and were less likely to
recommend prescription medication.
Bakerjian, D. (2008). Care of nursing home residents by advanced practice
nurses: A review of the literature. Research in Gerontological Nursing, 1(3),
177-185.
Bakerjian conducted and extensive review of the literature, particularly of NP-led
care. She found that long-term care patients managed by NPs were less likely to
have geriatric syndromes such as falls, UTIs, pressure ulcers, etc. They also had
improved functional status, as well as better managed chronic conditions.
Brown, S.A. & Grimes, D.E. (1995). A meta-analysis of nurse practitioners
and nurse midwives in primary care. Nursing Research, 44(6), 332-9.
A meta-analysis of 38 studies comparing a total of 33 patient outcomes of NPs
with those of physicians demonstrated that NP outcomes were equivalent to or
greater than those of physicians. NP patients had higher levels of compliance with
recommendations in studies where provider assignments were randomized and
when other means to control patient risks were used. Patient satisfaction and
resolution of pathological conditions were greatest for NPs. The NP and physician
outcomes were equivalent on all other outcomes.
Congressional Budget Office. (1979). Physician extenders: Their current and
future role in medical care delivery. Washington, D.C.: US Government
Printing Office.
As early as 1979, the Congressional Budget Office reviewed findings of the
numerous studies of NP performance in a variety of settings and concluded that
NPs performed as well as physicians with respect to patient outcomes, proper
diagnosis, management of specified medical conditions, and frequency of patient
satisfaction.
Cooper, M.A., Lindsay, G.M., Kinn, S., Swann, I.J. (2002). Evaluating
emergency nurse practitioner services: A randomized controlled trial.
Journal of Advanced Nursing, 40(6), 771-730.
A study of 199 patients randomly assigned to emergency NP-led care or
physician-led care in the U.K. demonstrated the highest level of satisfaction and
clinical documentation for NP care. The outcomes of recovery time, symptom
level, missed work, unplanned follow-up, and missed injuries were comparable
between the two groups.
Ettner, S.L., Kotlerman, J., Abdelmonem, A., Vazirani, S., Hays, R.D.,
Shapiro, M., et al. (2006). An alternative approach to reducing the costs of
patient care? A controlled trial of the multi-disciplinary doctor-nurse
practitioner (MDNP) model. Medical Decision Making, 26, 9-17.
16
Significant cost savings were demonstrated when 1207 patients in an academic
medical center were randomized to either standard treatment or to a physician-NP
model.
Horrocks, S., Anderson, E., Salisbury, C. (2002). Systematic review of
whether nurse practitioners working in primary care can provide equivalent
care to doctors. British Medical Journal, 324, 819-823.
A systematic review of 11 randomized clinical trials and 23 observational studies
identified data on outcomes of patient satisfaction, health status, cost, and/or
process of care. Patient satisfaction was highest for patients seen by NPs. The
health status data and quality of care indicators were too heterogeneous to allow
for meta-analysis, although qualitative comparisons of the results reported showed
comparable outcomes between NPs and physicians. NPs offered more
advice/information, had more complete documentation, and had better
communication skills than physicians. NPs spent longer time with their patients
and performed a greater number of investigations than did physicians. No
differences were detected in health status, prescriptions, return visits, or referrals.
Equivalency in appropriateness of studies and interpretations of x-rays were
identified.
Laurant, M., Reeves, D., Hermens, R., Braspenning, J., Grol, R., & Sibbald,
B. (2006). Substitution of doctors by nurses in primary care. Cochrane
Database of Systematic Reviews. 2006, Issue 1.
This meta-analysis included 25 articles relating to 16 studies comparing outcomes
of primary care nurses (nurses, NPs, clinical nurse specialists, or advance practice
nurses) and physicians. The quality of care provided by nurses was as high as that
of the physicians. Overall, health outcomes and outcomes such as resource
utilization and cost were equivalent for nurses and physicians. The satisfaction
level was higher for nurses. Studies included a range of care delivery models,
with nurses providing first contact, ongoing care, and urgent care for many of the
patient cohorts.
Lenz, E.R., Mundinger, M.O., Kane, R.L., Hopkins, S.C., & Lin, S.X. (2004).
Primary care outcomes in patients treated by nurse practitioners or
physicians: Two-year follow-up. Medical Care Research and Review 61(3),
332-351.
The outcomes of care in the study described by Mundinger, et al. in 2000 (see
below) are further described in this report including two years of follow-up data,
confirming continued comparable outcomes for the two groups of patients. No
differences were identified in health status, physiologic measures, satisfaction, or
use of specialist, emergency room, or inpatient services. Patients assigned to
physicians had more primary care visits than those assigned to NPs.
17
Lin, S.X., Hooker, R.S., Lens, E.R., Hopkins, S.C. (2002). Nurse practitioners
and physician assistants in hospital outpatient departments, 1997-1999.
Nursing Economics, 20(4), 174-179.
Data from the National Hospital Ambulatory Medical Care Survey (NHAMCS)
were used to identify patterns of NP and PA practice styles. NPs were more likely
to see patients alone and to be involved in routine examinations, as well as care
directed towards wellness, health promotion, disease prevention, and health
education than PAs, regardless of the setting type. In contrast, PAs were more
likely to provide acute problem management and to involve another person, such
as a support staff person or a physician.
Mundinger, M.O., Kane, R.L., Lenz, E.R., Totten, A.M., Tsai, W.Y., Cleary,
P.D., et al. (2000). Primary care outcomes in patients treated by nurse
practitioners or physicians: A randomized trial. Journal of the American
Medical Association, 283(1), 59-68.
The outcomes of care were measured in a study where patients were randomly
assigned either to a physician or to an NP for primary care between 1995 and
1997, using patient interviews and health services utilization data. Comparable
outcomes were identified, with a total of 1316 patients. After six months of care,
health status was equivalent for both patient groups, although patients treated for
hypertension by NPs had lower diastolic values. Health service utilization was
equivalent at both 6 and 12 months and patient satisfaction was equivalent
following the initial visit. The only exception was that at six months, physicians
rated higher on one component (provider attributes) of the satisfaction scale.
Newhouse, R. et al (2011). Advanced practice nurse outcomes 1999-2008: A
systematic review. Nursing Economic$, 29 (5), 1-22.
The outcomes of NP care were examined through a systematic review of 37
published studies, most of which compared NP outcomes with those of
physicians. Outcomes included measures such as patient satisfaction, patient
perceived health status, functional status, hospitalizations, ED visits, and biomarkers such as blood glucose, serum lipids, blood pressure. The authors
conclude that NP patient outcomes are comparable to those of physicians.
Office of Technology Assessment. (1986). Nurse practitioners, physician
assistants, and certified nurse midwives: A policy analysis. Washington D.C.:
US Government Printing Office.
The Office of Technology Assessment reviewed studies comparing NP and
physician practice, concluding that, “NPs appear to have better communication,
counseling, and interviewing skills than physicians have.” (p. 19) and that
malpractice premiums and rates supported patient satisfaction with NP care,
pointing out that successful malpractice rates against NPs remained extremely
rare.
18
Ohman-Strickland, P.A., Orzano, A.J., Hudson, S.V., Solberg, L.I., DiCiccioBloom, B., O’Malley, D., et al. (2008). Quality of diabetes care in family
medicine practices: Influence of nurse-practitioners and physician’s
assistants. Annals of Family Medicine, 6(1), 14-22.
The authors conducted a cross-sectional study of 46 practices, measuring
adherence to ADA guidelines. They reported that practices with NPs were more
likely to perform better on quality measures including appropriate measurement
of glycosylated hemoglobin, lips, and microalbumin levels and were more likely
to be at target for lipid levels.
Prescott, P.A. & Driscoll, L. (1980). Evaluating nurse practitioner
performance. Nurse Practitioner, 1(1), 28-32.
The authors reviewed 26 studies comparing NP and physician care, concluding
that NPs scored higher in many areas. These included: amount/depth of discussion
regarding child health care, preventative health, and wellness; amount of advice,
therapeutic listening, and support offered to patients; completeness of history and
follow-up on history findings; completeness of physical examination and
interviewing skills; and patient knowledge of the management plan given to them
by the provider.
Roblin, D.W., Becker, R., Adams, E.K., Howard, D. H., & Roberts, M.H.
(2004). Patient satisfaction with primary care: Does type of practitioner
matter? Medical Care, 42(6), 606-623.
A retrospective observational study of 41,209 patient satisfaction surveys
randomly sampled between 1997 and 2000 for visits by pediatric and medicine
departments identified higher satisfaction with NP and/or PA interactions than
those with physicians, for the overall sample and by specific conditions. The only
exception was for diabetes visits to the medicine practices, where the satisfaction
was higher for physicians.
Sacket, D.L., Spitzer, W. O., Gent, M., & Roberts, M. (1974). The Burlington
randomized trial of the nurse practitioner: Health outcomes of patients.
Annals of Internal Medicine, 80(2), 137-142.
A sample of 1598 families were randomly allocated, so that two-thirds continued
to receive primary care from a family physician and one-third received care from
a NP. The outcomes included: mortality, physical function, emotional function,
and social function. Results demonstrated comparable outcomes for patients,
whether assigned to physician or to NP care. Details from the Burlington trial
were also described by Spitzer, et al (see below).
Safriet, B. J. (1992). Health care dollars and regulatory sense: The role of
advanced practice nursing. Yale Journal on Regulation, 9(2).
The full Summer 1992 issue of this journal was devoted to the topic of advanced
practice nursing, including documenting the cost-effective and high quality care
19
provided, and to call for eliminating regulatory restrictions on their care. Safriet
summarized the OTA study concluding that NP care was equivalent to that of
physicians and pointed out that 12 of the 14 studies reviewed in this report which
showed differences in quality reported higher quality for NP care. Reviewing a
range of data on NP productivity, patient satisfaction, and prescribing, and data on
nurse midwife practice, Safriet concludes “APNs are proven providers, and
removing the many barriers to their practice will only increase their ability to
respond to the pressing need for basic health care in our country” (p. 487).
Spitzer, W.O., Sackett, D.L., Sibley, J.C., Roberts, M., Gent, M., Kergin,
D.J., Hacket, B.D., & Olynich, A. (1974). The Burlington randomized trial of
the nurse practitioner. New England Journal of Medicine, 290 (3), 252-256.
This report provides further details of the Burlington trial, also described by
Sackett, et al. (see above). This study involved 2796 patients being randomly
assigned to either one of two physicians or to an NP, so that one-third were
assigned to NP care, from July 1971 to July 1972. At the end of the period,
physical status and satisfaction were comparable between the two groups. The NP
group experienced a 5% drop in revenue, associated with absence of billing for
NP care. It was hypothesized that the ability to bill for all NP services would have
resulted in actual increased revenue of 9%. NPs functioned alone in 67% of their
encounters. Clinical activities were evaluated and it was determined that 69% of
NP management was adequate compared to 66% for the physicians. Prescriptions
were rated adequate for 71% of NPs compared to 75% for physicians. The
conclusion was that “a nurse practitioner can provide first-contact primary clinical
care as safely and effectively as a family physician” (p. 255).
Dulisse, B., & Cromwell, J. (2010). No harm found when nurse anesthetists
work without supervision by physicians. Health Affairs 29(8), 1469-1475.
There are no differences in patient outcomes when anesthesia services are
provided by Certified Registered Nurse Anesthetists (CRNAs), physician
anesthesiologists, or CRNAs supervised by physicians, according to the
examination of 500,000 individual cases. Currently, the Centers for Medicare &
Medicaid Services (CMS) prohibits Medicare payments to hospitals and
ambulatory surgery centers when CRNAs provide anesthesia care in the absence
of physician supervision. However, starting in 2001 CMS began allowing states to
“opt out” of the Medicare physician supervision requirement for CRNAs. Since
then 15 states have opted out. The study compared patient outcomes in states
where the supervision requirement is in place with patient outcomes in the 14
states that had opted out of the requirement between 2001 and 2005, and found
that inpatient deaths and complications did not differ.
Hogan, P.F., Seifert, R. F., Moore, C. S., Simonson, B.E. (2010). Cost
effectiveness analysis of anesthesia providers. Nursing Economic$ 28(3), 159169.
20
In order to define the most cost-effective anesthesia delivery model, the study’s
authors conducted simulation modeling and claims analysis using the Ingenix
national claims database of integrated medical and financial data from
commercial payers for 2008, which included 52,636 anesthesia deliveries, and the
2006 National Survey of Ambulatory Surgery (NSAS) which contains 52,223
visits. Different anesthesia delivery models in use in the United States today were
evaluated, including CRNAs acting solo, physician anesthesiologists acting solo,
and various models in which a single anesthesiologist directs or supervises one to
six CRNAs. The results show that CRNAs acting as the sole anesthesia provider
cost 25 percent less than the second lowest cost model. On the other end of the
cost scale, the model in which one anesthesiologist supervises one CRNA is the
least cost efficient model. The study’s authors also completed a comprehensive
review of nine published studies which compared the quality of anesthesia service
by provider type or delivery model. This review of published studies shows that
there are no measurable differences in quality of care between CRNAs and
anesthesiologists or by delivery model. The results of this study were particularly
compelling for people living in rural and other areas of the United States where
anesthesiologists often choose not to practice for economic reasons.
Hatem M, Sandall J, Devane D, Soltani H, Gates S. Midwife-led versus other
models of care for childbearing women. Cochrane Database of Systematic
Reviews 2008, Issue 4. Art. No.: CD004667. DOI:
10.1002/14651858.CD004667.pub2.
Midwife-led care has long been known to confer benefits to pregnant women and
their babies and is recommended. In many parts of the world, midwives are the
primary providers of care for childbearing women. The underpinning philosophy
of midwife-led care is normality, continuity of care and being cared for by a
known and trusted midwife during labor. There is an emphasis on the natural
ability of women to experience birth with minimum intervention. All models of
midwife-led care are provided in a multi-disciplinary network of consultation and
referral with other care providers. This was compared with models of medical-led
care and shared care, and identified 11 trials, involving 12,276 women. Midwifeled care was associated with several benefits for mothers and babies, and had no
identified adverse effects. The main benefits were a reduction in the use of
regional analgesia, with fewer episiotomies or instrumental births. there was no
difference in caesarean birth rates. Women who were randomized to receive
midwife-led care were less likely to lose their baby before 24 weeks' gestation,
although there were no differences in the risk of losing the baby after 24 weeks, or
overall. In addition, babies of women who were randomized to receive midwifeled care were more likely to have a shorter length of hospital stay.
DeSandre, C. A. (2000), Midwives As Primary Care Providers. Journal of
Midwifery & Women’s Health, 45: 81–83. doi: 10.1016/S1526-9523(99)000318
21
The ACNM's core competencies for midwifery education (5) state: Midwifery
education is based on a theoretical foundation in the health sciences as well as
clinical preparation which focuses on the knowledge, judgment, and skills deemed
necessary to provide primary care and independent management of women and
newborns within a health care system that provides for medical consultation,
collaborative management, or referral as appropriate. The role of midwifery in
primary care, as promulgated by the ACNM, is based on the Institute of
Medicine's definition of primary care and the ACNM's philosophy and position
statement on primary care. The ACNM's belief system of delivering care puts the
patient first while acknowledging the need for health care services that
accommodate diverse populations. Midwives increase women's access to primary
care services. They are ideal at developing therapeutic relationships with women,
which allows them to individualize health care plans that promote disease-free
lifestyles. During the 21st century, midwives may prove to be cost-effective
solutions to the health care provider shortage in this country. Through the
expansion of midwifery services, the primary health care needs of underserved
female populations can be better served and the goals of the Healthy People 2000
report (3) may actually be achieved.
According to Barton Associates, nurse practitioners (NP) are less likely to be named in a
malpractice suit than Physician Assistants or physicians as seen in research conducted by
the Federation of State Medical Boards, “NPs may decrease [malpractice] liability, at
least as viewed through the lens of a national reporting system.” (Amirault, 2013).
From 1991 to 2007, there was one malpractice claim filed for every 2.7 active physicians,
one for every 32.5 active PAs, and one claim filed for every 65.8 NPs (Amirault, 2013).
The AANP (2011) also reports data on malpractice claims filed against APRNs. Of
157,000 nurse practitioners practicing in the United States only 2% have been named as
defendants in malpractice cases (American Academy of Nurse Practitioners, 2012).
3a. The extent to which the proposal may restrict entry into the practice:
The proposal does not restrict the entry into practice. Current law includes the
following grandfather clause:
§30-7-1a. Eligibility for licensure by meeting requirements which existed
prior to the legislative enactments during the 2012 legislative session.
An applicant for licensure as an advanced practice registered nurse as set
forth in section one of this article who completed an advanced nursing
education program and was recognized, licensed or certified in an
advanced practice or a certified nurse midwife by West Virginia or
another state before December 31, 2012, may apply for and receive an
advanced practice registered nurse license if that applicant meets the
22
requirements that were in place in West Virginia at the time the applicant
qualified for initial advanced practice licensure.
3b. Whether the proposal requires practitioners in other jurisdictions who migrate to this
state to qualify in the same manner as state applicants, provided that the other jurisdiction
has substantially equivalent requirements as those in this state.
Practice is only restricted by an individual not meeting the basic requirements in the
current WV Code and Legislative Rules (§30-7-1 et seq.; §19-7-1 et seq.). The proposed
legislation does not alter these requirements.
The following legislative rule addresses endorsement for previously licensed APRNs
§19-7-5. Application for Licensure by Endorsement for an APRN
5.1. An applicant for licensure by endorsement as an APRN in this state
shall submit to the Board the required fee as specified in Series 12 Fees
rule, verification of eligibility for license or privilege to practice as an RN
in this state and a completed APRN application that provides evidence the
applicant meets the requirements of W. Va. Code §30-7-1.a. or evidence
of the following information:
5.1.a. Graduation from a graduate program accredited by a nurse
accrediting body that is recognized by the U.S. Department of Education
and/or the Council for Higher Education Accreditation (CHEA), or its
successor organization as acceptable by the Board.
5.1.b. Verification of completion as evidenced by official documentation
directly from a graduate program accredited by a nursing accrediting body
that is recognized by the U.S. Department of Education and/or the Council
for Higher Education Accreditation (CHEA), or its successor as acceptable
by the Board. Said verification shall include documentation verifying the
date of graduation, credential conferred, and clinical hours completed. On
and after January 1, 2015 the verification must include evidence of
completion of 3 separate graduate level courses in advanced physiology
and pathophysiology, advanced health assessment, advanced
pharmacology, which includes pharmacodynamics, pharmacokenetics and
pharmacotherapeutics of all broad categories of agents, role and
population focus of the education program, and evidence of meeting the
standards of nursing education in this state.
5.1.c. Demonstration of successful completion of approved APRN
certification program by providing the following:
23
5.1.c.1. Current certification by a national certifying body in the APRN
role and population focus appropriate to educational preparation.
5.1.c.2. Primary source verification of certification.
5.1.d. If the applicant has not been in clinical practice for more than the
past 2 years, the applicant shall provide evidence of satisfactory
completion of 24 contact hours, 12 in pharmacotherapeutics and 12 in the
clinical management of patients, within the two years prior to applying for
approval to practice.
5.1.e. If the applicant has not been in clinical practice for more than the
past 5 years, the applicant shall provide:
5.1.e.1. Evidence of satisfactory completion of 45 contact hours of
pharmacotherapeutics within the 2 years prior to application for approval
to practice.
5.1.e.2. The applicant shall also successfully complete a refresher course
or orientation program approved by the Board. An orientation
shall:
5.1.e.2.a. Include the appropriate advanced practice role and population
focus,
5.1.e.2.b. Be of sufficient length to satisfy the learning needs of the
inactive advanced practice nurse and to assure that the advanced practice
nurse meets the minimum standard for safe, competent care,
5.1.e.2.c. Cover the entire scope of the authorized advanced specialty area
with content that will include, but not be limited to, that which is specified
in Board guidelines, and,
5.1.e.2.d. Include a supervised clinical component by a qualified
preceptor who is a graduate prepared health care provider with comparable
practice focus and meets the following requirements:
5.1.e.2.d.1. Holds an active unencumbered license or privilege to
practice,
5.1.e.2.d.2. Is in current practice in the advanced role and population
foci, and,
24
5.1.e.2.d.3. Functions as a supervisor and teacher and evaluates the
individual’s performance in the clinical setting.
4. Provide a detailed state by state analysis of the scope of practice of this occupation.
Included in Appendix E are state-by-state scopes of practice tables from the NCSBN and
national specialty organizations for NPs, CNMs and CRNAs.
In short, the states surrounding West Virginia currently have the following statuary scope
of practice for APRNs:
In regard to Nurse Practitioners:
Maryland – Attestation agreement in which APRN lists the name of a physician
she would contact if she felt an issue was outside his/her training or education to
manage. The physician listed does not need to sign any part of the application and
has no oversight or supervisory position over the APRN. Thus Maryland is more
autonomous than WV.
Washington DC – Complete autonomous practice without any oversight,
supervision or statutorily required collaboration. Controlled substance prescribing
allowed by APRNs. APRNs can be involved in pain management programs if
specific requirements are met and can recommend medical marijuana. Thus
Washington DC is more autonomous than WV.
Ohio – Standard care arrangement contracts needed between APRNs and
physicians to practice and prescribe which includes the allowance of controlled
substances to be prescribed by APRNs as directed in standard care arrangement
contract. Thus Ohio is more autonomous in regards to prescribing controlled
substances than WV.
Kentucky – APRNs can practice autonomously. In order to prescribe, a
collaborative agreement with a physician must be in place. Prescription
limitations include the following medications which can only be permitted to be
prescribed for 30 day supply: Ativan, Valium, Soma, Klonopin, Xanax.
Otherwise, controlled substances may be prescribed (schedule II or above) as
defined in collaborative agreement to prescribe without regulatory restrictions.
Thus Kentucky is more autonomy than WV in regards to prescribing controlled
substances.
Pennsylvania – Collaborative agreement with physician needed to practice and
prescribe. APRNs can sign death certificates and order home health. Schedule II
drugs can be prescribed for 30 days; Schedule III & IV for 90 days. Thus
Pennsylvania is more autonomous than WV in regards to prescribing controlled
25
substances.
In regard to CRNAs:
CRNAs in Maryland, Ohio and Pennsylvania are not eligible for prescriptive
authority. Prescriptive authority for Kentucky CRNAs requires a written
collaborative agreement with a physician. CRNAs in Washington DC may
prescribe independently.
In regard to CNMs
CNMs and CMs attended 313,516 births in 2009, according to the National
Center for Health Statistics. This represents 11.3% of all vaginal births, or 7.6%
of all US births. The proportion of CNM/CM attended births has risen nearly
every year since 1989, the first year that CNM/CM statistics were made available.
In West Virginia, the percentage of midwife-attended births is closer to 13%.
(Natl Vital Stat Rep, 2010)
There are currently 62 Certified Nurse Midwives (CNMs) practicing in West
Virginia. Charleston, Huntington, Beckley and Martinsburg have the greatest
number of CNMs. There are 69 nurse-midwifery practice sites in West Virginia.
The West Virginia Health Care Planning Commission included nurse-midwives in
its comprehensive reform plan, saying, "We affirm the value of...nursemidwives...as primary providers...who are improving access to care." (2008).
Not only is it important to compare WV to surrounding states but it is also important to note the
effects full practice authority has in rural areas. The following table provides side by side
comparisons of four states where APRNs have full practice authority. The table shows the
percentage of state population living in rural areas and the percentage of NPs practicing in rural
areas. As this table illustrates, evidence shows that more APRNs practice in rural areas when
they have full practice authority (Golden, 2012).
Table 2. Comparison of States with Full Practice Authority
State
IOWA
MAINE
MONTANA
WYOMING
Percent of population in
rural areas
38.9%
59.3%
45.9%
34.%
Percent of NPs practicing in
rural areas
37%
39%
40%
43%
5. Identify other occupations whose scopes of practice may overlap with the proposal.
The other occupations with which APRNs’ scopes of practice may overlap include, but
are not limited to: Medical Doctors (MDs), Doctors of Osteopathic Medicine (DOs),
26
Doctors of Podiatric Medicine (DPMs), Doctors of Dental Surgery (DDSs) &
Optometrists.
The primary goal for all APRNs is a positive outcome for their patients. In order to
deliver quality care, it is often necessary to interact and verbally collaborate with other
health care professionals. These interactions may take place by referrals, phone calls,
electronic correspondence and, at times, face to face consultations. This overlap and
verbal collaboration is already in place and is incorporated daily by all APRNs.
In 2006, members of regulatory boards representing medicine, nursing, occupational
therapy, pharmacy, physical therapy and social work got together in a collaborative effort
to make recommendations to legislators regarding scope of practice expansion for
healthcare professionals. The document published includes the following comments
regarding overlapping of healthcare professionals practice (National Council of State
Boards of Nursing, 2006):
“Overlap among professions is necessary. No one profession actually owns a skill
or activity in and of itself. One activity does not define a profession, but it is the
entire scope of activities within the practice that makes any particular profession
unique. Simply because a skill or activity is within one profession’s skill set does
not mean another profession cannot and should not include it in its own scope of
practice.”
6. Provide a detailed analysis of the cost to the state, to the practitioners and to the general
public of implementing the proposed increase in scope of practice.
There is no increased cost to the state from this proposal. The WV RN Board reports:
“Board funding is from licensing fees. The APRN licensee fee has been $35 for
announcement of advanced practice in WV since 2002 (§19-12-1 et seq.). The
prescriptive authority fee has been $125 since 1992. Both fees will need to be increased
to fund staffing to support these growing areas of nursing regulation. The fee change will
go through legislative process before implementation.”
Currently, all APRNs who have prescriptive authority must maintain a collaborative
relationship with a physician in order to prescribe medication. There are a range of
concerns about the collaborative agreement. For example: One APRN is the sole
proprietor of a practice, which employs six other APRNs, one PA, and one MD
(Hamilton, 2013). This APRN has simply responded to the demands of the market, has a
good reputation in the town as avowed by many of her MD colleagues. If the MD in her
office (who is 62) decides to leave, relocate, or retire, she will essentially have to shut the
practice doors overnight or scramble to find another MD/DO to sign another
collaborative agreement. With a patient base of over 5,000, abrupt closure of the practice
doors could be catastrophic, not to mention concerns regarding the potential ethical
dilemma which would result if she were unable to fulfill her obligation to care for her
27
patients.
Another APRN who owns a primary care clinic in Morgantown also has the required
collaborative agreement in order to prescribe medication (DiChiacchio, 2013). As part of
this agreement, she must pay a physician collaborator $250 per hour for any work he does
auditing charts. In addition, she is required to purchase a malpractice insurance rider to
cover him in this role as a collaborator, even though current WV law exempts him from
liability for her practice. These physician imposed requirements to sign her required
agreement creates an increased cost to the APRN of $10,000 per year.
"Cost-effectiveness analysis clearly supports reversing rules and regulations that deny
reimbursement to nurse practitioners, while paying more expensive health professionals
for clinical services that achieve comparable results…Nurse Practitioners are truly an
underutilized resource for cost-effective health reform" (Bauer, 2010).
Further, regarding cost of care, APRNs are a proven response to the evolving trend
towards wellness and preventive health care driven by consumer demand. A solid body of
evidence demonstrates that APRNs have consistently proven to be cost-effective
providers of high-quality care for almost 50 years. Examples of the APRN costeffectiveness research are described below.
Over three decades ago, the Office of Technology Assessment (OTA) (1981) conducted
an extensive case analysis of APRN practice, reporting that APRNs provided equivalent
or improved medical care at a lower total cost than physicians. APRNs in a physician
practice potentially decreased the cost of patient visits by as much as one third,
particularly when seeing patients in an independent, rather than complementary, manner
(Office of Technology Assessment, 1981).
A subsequent OTA analysis (1986) confirmed original findings regarding APRN cost
effectiveness (Office of Technology Assessment, 1986). All later studies of APRN care
have found similar cost-efficiencies associated with APRN practice. The costeffectiveness of APRNs begins with their academic preparation. The American
Association of Colleges of Nursing has long reported that APRN preparation cost 2025% that of physicians. In 2009, the total tuition cost for APRN preparation was less than
one-year tuition for medical (MD or DO) preparation (American Academy of Nurse
Practitioners, 2010).
Comparable savings are associated with APRN compensation. In 1981, the hourly cost of
an APRN was one-third to one-half that of a physician (OTA). The difference in
compensation has remained unchanged for 30 years. In 2010, when the median total
compensation for primary care physicians ranged from $208,658 (family) to $219,500
(internal medicine), the mean full-time APRN’s total salary was $97,345, across all types
of practice (American Medical Group Association, 2011; American Academy of Nurse
Practitioners, 2010). A study of 26 capitated primary care practices with approximately
28
two million visits by 206 providers determined that the practitioner labor costs and total
labor costs per visit were both lower in practices where APRNs and physician assistants
(PAs) were used to a greater extent (Roblin, 2004). When productivity measures, salaries,
and costs of education are considered, APRNs are cost effective providers of health
services.
Based on a systematic review of 37 studies, Newhouse et al (2011) found consistent
evidence that cost-related outcomes such as length of stay, emergency visits, and
hospitalizations for APRN care are equivalent to those of physicians (Newhouse et al,
2011). In 2012, modeling techniques were used to predict the potential for increased
APRN cost-effectiveness into the future, based on prior research and data. Using Texas
as the model State, Perryman (2012) analyzed the potential economic impact that would
be associated with greater use of APRNs and other advanced practice nurses, projecting
over $16 billion in immediate savings which would increase over time.
APRN cost-effectiveness is not dependent on actual practice setting and is demonstrated
in primary care, acute care, and long term care settings. For instance, APRNs practicing
in Tennessee’s state-managed managed care organization (MCO) delivered health care at
23% below the average cost associated with other primary care providers, achieving a
21% reduction in hospital inpatient rates and 24% lower lab utilization rates compared to
physicians (Spitzer, 1994).
A one-year study comparing a family practice physician-managed practice with an
APRN-managed practice within an MCO found that compared to the physician practice,
the APRN-managed practice had 43% of the total emergency department visits, 38% of
the inpatient days, and 50% total annualized per member monthly cost (Jenkins &
Torrisi, 1995). Nurse managed centers (NMCs) with APRN-provided care, have
demonstrated significant savings, less costly interventions, and fewer emergency visits
and hospitalizations (Hunter, Ventura, & Kearns, 1999; Coddington, Sands, Edwards,
Kirkpatrick, & Chen, 2011). A study conducted in a large HMO setting established that
adding an APRN to the practice could virtually double the typical panel of patients seen
by a physician with a projected increase in revenue of $1.28 per member per month, or
approximately $1.65 million per 100,000 enrollees annually (Burl, Bonner, & Rao,
1994).
Chenowith, Martin, Pankowski, and Raymond (2005) analyzed the health care costs
associated with an innovative on-site APRN practice for over 4000 employees and their
dependents, finding savings of $ .8 to 1.5 million, with a benefit-to-cost ratio of up to 15
to 1. Later, they tested two additional benefit-to-cost models using 2004-2006 data for
patients receiving occupational health care from an APRN demonstrating a benefit to cost
ratio ranging from 2.0-8.7 to 1, depending on the method (Chenowith, Martin,
Pankowski, & Raymond, 2005). Time lost from work was lower for workers managed by
APRNs, compared to physicians, as another aspect of cost-savings (Sears, Wiekizer,
Franklin, Cheadle, & Berkowitz, 2007).
29
A number of studies have documented the cost-effectiveness of APRNs in managing the
health of older adults. Hummel and Prizada (1994) found that compared to the cost of
physician-only teams, the cost of a physician-APRN team long term care facility were
42% lower for the intermediate and skilled care residents and 26% lower for those with
long-term stays. The physician-APRN teams also had significantly lower rates of
emergency department transfers, shorter hospital lengths of stay, and fewer specialty
visits.
A one-year retrospective study of 1077 HMO enrollees residing in 45 long term care
settings demonstrated a $72 monthly gain per resident, compared with a $197 monthly
loss for residents seen by physicians alone (Burl, Bonner, & Rao, 1994). Intrator (2004)
found that residents in nursing homes with APRNs were less likely to develop
ambulatory care-sensitive diagnoses requiring hospitalizations. Bakerjian (2008)
summarized a review of 17 studies comparing nursing home residents who are patients of
APRNs to others, finding lower rates of hospitalization and overall costs for the APRN
patients.
The potential for APRNs to control costs associated with the healthcare of older adults
was recognized by United Health (2009), which recommended that providing APRNs to
manage nursing home patients could result in $166 billion healthcare savings.
APRN-managed care within acute-care settings is also associated with lower costs. Chen,
McNeese-Smith, Cowan, Upenieks, and Afifi (2009) found that APRN-led care was
associated with lower overall drug costs for inpatients. When Paez and Allen (2006)
compared APRN and physician management of hypercholesterolemia following
revascularization, they found patients in the APRN-managed group had lower drug costs,
while being more likely to achieve their goals and comply with prescribed regimen (Paez
& Allen, 2006). Collaborative APRN/physician management was associated with
decreased length of stay and costs and higher hospital profit, with similar readmission
and mortality rates (Cowan, Shapiro, & Hayes, 2006; Ettner, Kotlerman, & Afifi, 2006).
The introduction of an APRN model in a health system’s neuroscience area resulted in
over $2.4 million savings the first year and a return on investment of 1600 percent;
similar savings and outcomes were demonstrated as the APRN model was expanded in
the system (Larkin, 2003) . Boling (2009) cites an intensive short-term transitional care
APRN program documented by Smigleski et al through which healthcare costs were
decreased by 65% or more after enrollment, as well as the introduction of an APRN
model in a system’s cardiovascular area associated with a decrease in mortality from
3.7% to 0.6% and over 9% decreased cost per case (from $27,037 to $24,511).
Recently, one physician, Dr. Adalja, lauded that “Sometimes best medical care is
provided by those who are not MDs.” This article notes that one solution to the rising
cost of care – that can actually work (APRNs) is “hampered by onerous licensing laws
30
and guild-minded state government medical boards, is to allow all health professionals to
render care independent of a physician if they (and their patients) so choose.” (Adalja,
2013)
With regard to physician wages, Pittman and Williams (2012) completed an analysis of
physicians’ wages in 14 of 17 states that have full practice authority. They concluded that
expanded scope of practice laws had no impact on physicians’ earnings (Pittman &
Williams, 2012).
The Perryman Report (2012), an internationally recognized economist, estimates that the
medical cost savings resulting from the efficiencies created by greater utilization of
APRNs by removing some of the existing legal barriers would yield a broader economic
impact that includes over $8 Billion in gross product and over 97,000 new jobs, annually;
an estimate that he assures is conservative. The overall economic stimulus is over $16
Billion, plus there is a gain to state and local sales tax revenue of over $480 Million and
$230 Million, respectively (Perryman Group, 2012).
In addition to absolute cost, other factors are important to health care cost-effectiveness.
These include illness prevention, health promotion, and outcomes. See Documentation of
Quality of Nurse Practitioner Practice for further discussion (American Association of
Nurse Practitioners, 2013).
7. Provide a copy of the proposed legislation.
A BILL to amend and reenact §30-7-15a, §30-7-15b and §30-7-15c of the Code of West
Virginia, 1931, as amended; and to amend and reenact §30-15-7, §30-15-7a, §30-15-7b
and §30-15-7c of said code, all relating to expanding prescriptive authority of Advanced
Practice Registered Nurses (APRN); and removing the requirement for written
collaborative regulation requirement with a physician; and global signature allowance of
documents for APRNs.
Be it enacted by the Legislature of West Virginia:
That §30-7-15a, §30-7-15b and §30-7-15c of the Code of West Virginia, 1931, as
amended, be amended and reenacted; and that §30-15-7, §30-15-7a, §30-15-7b and §3015-7c of said code be amended and reenacted, all to read as follows:
ARTICLE 7. REGISTERED PROFESSIONAL NURSES.
§30-7-15a. Prescriptive authority for prescription drugs; coordination with Board of
Pharmacy.
(a) The board may, in its discretion, authorize an advanced practice registered
nurse to prescribe prescription drugs in a collaborative relationship with a physician
licensed to practice in West Virginia and in accordance with applicable state and federal
laws. An authorized advanced practice registered nurse may write or sign prescriptions or
31
transmit prescriptions verbally or by other means of communication.
(b) For purposes of this section an agreement to a collaborative relationship for
prescriptive practice between a physician and an advanced practice registered nurse shall
be set forth in writing. Verification of the agreement shall be filed with the board by the
advanced practice registered nurse. The board shall forward a copy of the verification to
the Board of Medicine and the Board of Osteopathic Medicine. Collaborative agreements
shall include, but are not limited to, the following:
(1) Mutually agreed upon written guidelines or protocols for prescriptive
authority as it applies to the advanced practice registered nurse's clinical practice;
(2) Statements describing the individual and shared responsibilities of the
advanced practice registered nurse and the physician pursuant to the collaborative
agreement between them;
(3) Periodic and joint evaluation of prescriptive practice; and
(4) Periodic and joint review and updating of the written guidelines or protocols.
(c) (b) The board shall promulgate legislative rules in accordance with the
provisions of chapter twenty-nine-a of this code governing the eligibility and extent to
which an advanced practice registered nurse may prescribe drugs. Such rules shall
provide, at a minimum, a state formulary classifying those categories of drugs which
shall not be prescribed by advanced practice registered nurse including, but not limited
to, Schedules I and II of the Uniform Controlled Substances Act, antineoplastics,
radiopharmaceuticals and general anesthetics. Drugs listed under Schedule III shall be
limited to a seventy-two hour supply without refill. In addition to the above referenced
provisions and restrictions and pursuant to a collaborative agreement as set forth in
subsections (a) and (b) of this section, the rules and shall permit the prescribing of an
annual supply of any drug, with the exception of controlled substances, which is
prescribed for the treatment of a chronic condition, other than chronic pain management.
For the purposes of this section, a "chronic condition" is a condition which lasts three
months or more, generally cannot be prevented by vaccines, can be controlled but not
cured by medication and does not generally disappear. These conditions, with the
exception of chronic pain, include, but are not limited to, arthritis, asthma, cardiovascular
disease, cancer, diabetes, epilepsy and seizures, and obesity. The prescriber authorized in
this section shall note on the prescription the chronic disease being treated.
(d) The board shall consult with other appropriate boards for the development of
the formulary.
(e) (c) The board shall transmit to the Board of Pharmacy a list of all advanced
practice registered nurse with prescriptive authority. The list shall include:
(1) The name of the authorized advanced practice registered nurse;
(2) The prescriber's identification number assigned by the board; and
32
(3) The effective date of prescriptive authority.
§30-7-15b. Eligibility for prescriptive authority; application; fee.
An advanced practice registered nurse who applies for authorization to prescribe
drugs shall:
(a) Be licensed and certified in West Virginia as an advanced practice registered
nurse;
(b) Not be less than Be at least eighteen years of age;
forty-five contact hours of education in pharmacology and clinical management of drug
therapy under a program approved by the board, fifteen hours of which shall be
completed within the two-year period immediately before the date of application;
(d) Provide the board with evidence that he or she is a person of good moral
character and not addicted to alcohol or the use of controlled substances; and
(e) Submit a completed, notarized application to the board, accompanied by a
fee as established by the board by rule.
§30-7-15c. Form of prescriptions; termination of authority; renewal; notification of
termination of authority.
(a) Prescriptions authorized by an advanced practice registered nurse must
comply with all applicable state and federal laws; must be signed by the prescriber with
the initials "A.P.R.N." or the designated certification title of the prescriber; and must
include the prescriber's identification number assigned by the board or the prescriber's
national provider identifier assigned by the National Provider System pursuant to 45 C. F.
R. §162.408.
(b) Prescriptive authorization shall be terminated if the advanced practice
registered nurse has:
(1) Not maintained current authorization as an advanced practice registered
nurse; or
(2) Prescribed outside the advanced practice registered nurse's scope of practice
or has prescribed drugs for other than therapeutic purposes. or
(3) Has not filed verification of a collaborative agreement with the board.
(c) Prescriptive authority for an advanced practice registered nurse must be
renewed biennially. Documentation of eight contact hours of pharmacology during the
previous two years must be submitted at the time of renewal.
(d) The board shall notify the Board of Pharmacy the Board of Medicine and the
Board of Osteopathic Medicine within twenty-four hours after termination of, or change
in, an advanced practice registered nurse's prescriptive authority.
30-7-15d. Allowance of APRN’s for global signatures on patient care
documentations.
33
(a) Whenever any law or regulation requires a signature, certification, stamp, verification,
affidavit or endorsement by a physician, it shall be deemed equal to include a signature,
certification, stamp, verification, affidavit or endorsement by an advanced practice
registered nurse.
ARTICLE 15. NURSE-MIDWIVES.
§30-15-7. Standards of practice.
The license to practice nurse-midwifery shall entitle entitles the holder to
practice such the profession according to the statement of standards of the American
College of Nurse- Midwives. and such holder shall be required to practice in a
collaborative relationship with a licensed physician engaged in family practice or the
specialized field of gynecology or obstetrics, or as a member of the staff of any
maternity, newborn or family planning service approved by the West Virginia
Department of Health and Human Resources, who, as such, shall practice nursemidwifery in a collaborative relationship with a board-certified or board-eligible
obstetrician, gynecologist or the primary-care physician normally directly responsible for
obstetrical and gynecological care in said area of practice.
§30-15-7a. Prescriptive authority for prescription drugs; promulgation of rules;
classification of drugs to be prescribed; coordination with Board of Pharmacy.
(a) The board shall, in its discretion, authorize a nurse- midwife to prescribe
prescription drugs in a collaborative relationship with a physician licensed to practice in
West Virginia and in accordance with applicable state and federal laws. An authorized
nurse-midwife may write or sign prescriptions or transmit prescriptions verbally or by
other means of communication.
(b) For purposes of this section an agreement to a collaborative relationship for
practice between a physician and a nurse-midwife shall be set forth in writing.
Verification of such agreement shall be filed with the board by the nurse-midwife. The
board shall forward a copy of such verification to the Board of Medicine. Collaborative
agreements shall include, but not be limited to, the following:
(1) Mutually agreed upon written guidelines or protocols for prescriptive
practice as it applies to the nurse-midwife's clinical practice;
(2) Statements describing the individual and shared responsibilities of the nursemidwife and the physician pursuant to the collaborative agreement between them;
(3) Periodic and joint evaluation of prescriptive practice; and
(4) Periodic and joint review and updating of the written guidelines or protocols.
(c) (b) The board shall promulgate legislative rules in accordance with the
provisions of chapter twenty-nine-a of this code governing the eligibility and extent to
which a nurse-midwife may prescribe drugs. Such rules shall provide, at a minimum, a
state formulary classifying those categories of drugs which shall not be prescribed by
34
nurse-midwives, including, but not limited to, Schedules I and II of the Uniform
Controlled Substances Act, anticoagulants, antineoplastics, radio-pharmaceuticals and
general anesthetics. Drugs listed under schedule III shall be limited to a seventy-two hour
supply without refill.
(d) The board shall consult with other appropriate boards for development of the
formulary.
(e) (c) The board shall transmit to the Board of Pharmacy a list of all nursemidwives with prescriptive authority. The list shall include:
(1) The name of the authorized nurse-midwife;
(2) The prescriber's identification number assigned by the board; and
(3) The effective date of prescriptive authority.
§30-15-7b. Eligibility for prescriptive authority; application; fee.
A nurse-midwife who applies for authorization to prescribe drugs shall:
(a) Be licensed and certified as a nurse-midwife in the State of West Virginia;
(b) Not be less than Be at least eighteen years of age;
(c) Provide the board with evidence of successful completion of forty-five
contact hours of education in pharmacology and clinical management of drug therapy
under a program approved by the board, fifteen of which shall be completed within the
two-year period immediately before the date of application;
(d) Provide the board with evidence that he or she is a person of good moral
character and not addicted to alcohol or the use of controlled substances; and
(e) Submit a completed, notarized application to the board, accompanied by a
fee of $125 as established by the board by rule.
§30-15-7c. Form of prescription; termination of authority; renewal; notification of
termination of authority.
(a) Prescriptions authorized by a nurse-midwife must comply with all applicable
state and federal laws; must be signed by the prescriber with the initials "C.N.M."; and
must include the prescriber's identification number assigned by the board.
(b) Prescriptive authorization shall be terminated if the nurse-midwife has:
(1) Not maintained current authorization as a nurse-midwife; or
(2) Prescribed outside the nurse-midwife's scope of practice or has prescribed
drugs for other than therapeutic purposes. or
(3) Has not filed verification of a collaborative agreement with the board.
(c) Prescriptive authority for a nurse-midwife must be renewed biennially.
Documentation of eight contact hours of pharmacology during the previous two years
must be submitted at the time of renewal.
(d) The board shall notify the Board of Pharmacy and the Board of
35
Medicine within twenty-four hours after termination of, or change in, a nurse-midwife's
prescriptive authority.
NOTE: The purpose of this bill is to retire language that creates barriers to
APRN practice, to update state law and to increase access to care for all West Virginians.
Strike-throughs indicate language that would be stricken from the present law
and underscoring indicates new language that would be added.
36
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Larkin, H. (2003). Retrieved from The case for nurse practitioners:
http://www.hhnmag.com/hhnmag/jsp/articledisplay.jsp?dcrpath=AHA/PubsNewsArticle/data/0308HHN_F
EA_NursePractitioners&domain=HHNMAG
National Council of State Boards of Nursing. (2006, May). Changes In Healthcare Professionals Scope of Practice:
Legislative Considerations.
National Council of State Boards of Nursing. (2012, June). APRN Maps: Independent Prescribing. Retrieved May
16, 2013, from National Council of State Boards of Nursing.
National Council of States Board of Nursing. (2008). Consensus Model for APRN Regulation: Licensure,
Accreditation, Certification & Education.
National Governor's Association. (2012, December). The role of nurse practitioners in meeting increasing demand
for primary care. Retrieved from National Govenor's Association:
http://www.nga.org/files/live/sites/NGA/files/pdf/1212NursePractitionersPaper.pdf
Newhouse, R. H. (2011). Advanced practice nurse outcomes 1990-2008. Retrieved from Nursing Economics:
http://midwife.org/ACNM/files/ccLibraryFiles/Filename/000000001305/Advance%20Practice%20Nurse%
20Outcomes%20article.pdf
Office of Technology Assessment. (1981). The cost effectiveness of nurse practitioners. Washington DC: US
Government Printing Office.
Office of Technology Assessment. (1986). Nurse practitioners, physicians assistant & certified nurse midwives: a
policy analysis. Retrieved from http://www.fas.org/ota/reports/8615.pdf
Paez, A., & Allen, J. (2006). Cost effectiveness of nurse practitioners management of hypercholesteremia following
coronary revascularization. Journal of American Academy of Nurse Practitioners, 436-444.
Perryman Group. (2012). The economic benefits of more fully utilizing advanced practice registered nurses in the
provision of care in Texas. Waco TX.
Pittman, P., & Williams, B. (2012). Physician wages in states with expanded APRN scope of practice. Retrieved
from Robert Woods Johnson Foundation: http://www.rwjf.org/en/research-publications/find-rwjfresearch/2012/01/physician-wages-in-states-with-expanded-aprn-scope-of-practice.html
Roblin, D. H. (2004). Use of midlevel practitioners to achieve labor cost savings in the primary care practice of an
MCO. Health Services Research, 607-626.
Sears, J., Wiekizer, T., Franklin, G., Cheadle, A., & Berkowitz, B. (2007). Nurse practitioner as attending providers
for workers with uncomplicated back injuries: using administrative data to evaluate quality & process of
care. Journal of Occupational Environmental Medicine, 900-8.
Spitzer, R. (1994). The vanderbilt experience. Nursing Management, 38-40.
United States Census Bureau. (2012, August 16). State and County QuickFacts. Retrieved September 8, 2012, from
38
http://quickfacts.census.gov/qfd/states/54000.html#
United States Department of Agriculture. (2012). State fact sheets: West Virgnina. Retrieved from
http://www.ers.usda.gov/StateFacts/WV.htm
West Virginia Legislature. (2012). Senate Concurrent Resolution 93.
West Virginians for Affordable Health Care. (2012). What the affordable care act means to women and families.
Retrieved May 16, 2013, from West Virginians for Affordable Health Care:
http://www.wvahc.org/downloads/Final_The_ACA_What_Health_Reform_Means_to_Women_and_Famili
es.pdf
WV Board of Examiners for Registered Professional Nurses. (2012, December 11). Annual Report of the Biennium:
July1, 2010 to June 30, 2012. Retrieved from
http://www.legis.state.wv.us/legisdocs/reports/agency/R02_FY_2012_1773.pdf
39
APPENDIXES:
Appendix A – Federal Trade Commission Testimony
Appendix B – Health Professional Shortage Areas (HPSAs)
Appendix C – Distribution of Birthing Services in WV
Appendix D – ANA Code of Ethics
Appendix E – State-by-state Scopes of Practice Tables
Appendix F – Letters of Support
40
Appendix A
PREPARED STATEMENT OF
THE FEDERAL TRADE COMMISSION STAFF
Before
Subcommittee A of the Joint Committee on Health
Of the
State of West Virginia Legislature
On
The Review of West Virginia Laws Governing the Scope of Practice for Advanced Practice
Registered Nurses and Consideration of Possible Revisions to Remove Practice Restrictions
September 10-12, 2012
41
I. INTRODUCTION
The staffs of the Federal Trade Commission’s Office of Policy Planning, Bureau of
Competition, and Bureau of Economics1 appreciate the opportunity to respond to Senator Daniel
Foster’s invitation for testimony on West Virginia’s laws governing Advanced Practice
Registered Nurses’ (“APRNs’”)2 scope of practice, as well as for recommendations the FTC staff
deem “appropriate to protect the public while simultaneously allowing for an efficient and
procompetitive market.”3 Senator Foster specifically noted that West Virginia law allows
APRNs to diagnose and treat patients without physician involvement, but requires APRNs to
have a signed collaboration agreement with a physician in order to prescribe medications.
Senator Foster’s invitation highlights West Virginia Senate Concurrent Resolution No.
93, which recommends a study of “the scope of practice of advanced practice nurses and the
need for its expansion to improve the quality of health care, increase patient access and to allow
patients free choice of their health care providers.”4 Senator Foster states that the review of
current law is in part responsive to the Institute of Medicine’s (“IOM”) request that state
legislatures review and reform, if necessary, scope of practice regulations on APRNs.5 He further
indicated that this review is an opportunity for the West Virginia legislature to fulfill its duty to
provide West Virginians “with a healthcare marketplace that is safe, open, and robust.”6
As Concurrent Resolution No. 93 recognizes, recent reports by the IOM have identified a
key role for advanced practice nurses in improving the delivery of health care.7 The IOM,
established in 1970 as the health arm of the National Academy of Sciences, provides expert
advice to policy makers and the public and has conducted an intensive examination of issues
surrounding advanced nursing practice. Among other things, the IOM found that advanced
42
practice nurses can help improve access to health care and “[r]estrictions on scope of practice. . .
have undermined [nurses’] ability to provide and improve both general and advanced care.”8
West Virginians are particularly vulnerable to access issues caused by physician
shortages. West Virginia currently suffers from shortages of primary care providers, and these
shortages are expected to worsen as more West Virginians gain health insurance and seek access
to primary health care services.9 Legislative action to eliminate the collaborative agreement
requirement for prescriptive authority may improve access and consumer choice for primary care
services, especially for rural and other underserved populations, and also may encourage
beneficial price competition that could help contain health care costs.
Given the potential benefits of eliminating unwarranted impediments to APRN practice,
we applaud the West Virginia legislature’s efforts to review and study the statutory limits on
APRNs, and we recommend that the legislature ensure that such limits are no stricter than patient
protection requires. We encourage the legislature to carefully consider available safety evidence
on APRN practice in West Virginia and elsewhere. Absent a finding that there are countervailing
patient care and safety concerns regarding APRN practice, suggestions to remove the
collaborative agreement for prescriptive authority appear to be a procompetitive improvement in
the law that likely would benefit West Virginia health care consumers.
II. INTEREST AND EXPERIENCE OF THE FTC
The FTC is charged under the FTC Act with preventing unfair methods of competition
and unfair or deceptive acts or practices in or affecting commerce.10 Competition is at the core of
America's economy,11 and vigorous competition among sellers in an open marketplace gives
consumers the benefits of lower prices, higher quality products and services, more choices, and
43
greater innovation. Because of the importance of health care competition to the economy and
consumer welfare, anticompetitive conduct in health care markets has long been a key target of
FTC law enforcement,12 research,13 and advocacy.14 Recently, FTC staff have analyzed the likely
competitive effects of proposed APRN regulations in other states.15
III. BACKGROUND: APRN PRACTICE IN WEST VIRGINIA
APRNs are licensed by the West Virginia Board of Examiners for Registered
Professional Nursing and subject to the Board’s regulations.16 West Virginia law states:
The practice of “advanced practice registered nurse” is a registered nurse who
has acquired advanced clinical knowledge and skills preparing him or her to
provide direct and indirect care to patients, who has completed a board approved
graduate-level education program and who has passed a board approved
national certification examination. An advanced practice registered nurse
shall meet all the requirements set forth by the board by rule for an advance
practice registered nurse which shall include, at a minimum, a valid license
to practice as a certified registered nurse anesthetist, a certified nurse midwife,
a clinical nurse specialist or a certified nurse practitioner.17
APRNs were first recognized by the West Virginia Legislative Rules beginning in
1991.18 In 1993, the requirements for prescriptive authority were set forth in the West Virginia
Code and Legislative Rules, including the requirement that prescribing APRNs have a signed
collaboration agreement with a West Virginia physician.19 Although collaborative agreements
could, in theory, encompass varying arrangements, the IOM Report observes that West Virginia
law imposes no requirements for on-site supervision of APRNs, the frequency or extent to which
44
physicians must review the charts of APRN patients, or the maximum number of APRNs with
whom a physician may have collaborative arrangements.20
IV. LIKELY COMPETITIVE BENEFITS OF EXPANDING APRN PRESCRIPTIVE
AUTHORITY
FTC staff recognize that certain professional licensure requirements are necessary to
protect patients. Consistent with patient safety, however, we urge legislators to also consider the
potential benefits of competition, including improved access to care, lower costs, and increased
options, that removal of restrictions on APRN practice would likely create.
a. Removing Restrictions Is Likely to Improve Access to Primary Care Services
The United States faces substantial and growing shortages of physicians.21While these
shortages will exacerbate health care access problems for many American consumers, the impact
of reduced access is likely to be most acute among Medicaid beneficiaries, due to fewer
physician practices located in low-income communities, as well as low physician participation in
state Medicaid programs.22
The West Virginia legislature recognized access problems in Resolution No. 93: “The
health care model in place, despite its established history, has not been successful in providing
care to all patients in West Virginia, including the uninsured.” 23 In fact, 44 of 55 West Virginia
counties contain federally-designated Health Professional Shortage Areas (“HPSAs”).24
Moreover, federal health care reform will greatly expand the number of people with insurance in
West Virginia, likely increasing the demand for primary care services and potentially
exacerbating the imbalance between demand for and supply of primary care physicians.
45
Beginning in 2014, as many as 178,300 West Virginians will be eligible for tax credits to
purchase private health insurance policies and an additional 122,000 low-income West
Virginians may become eligible for Medicaid.25
APRNs are seen by many as crucial to addressing access problems. As a general matter,
APRNs make up a greater share of the primary care workforce in less densely populated, less
urban, and lower income areas, as well as in federally-designated HPSAs. APRNs also are more
likely than primary care physicians to care for large numbers of minority patients, Medicaid
beneficiaries, and uninsured patients.26 It is also important to note that APRNs are the fastest
growing segment of the primary care professional workforce in the United States. Between the
mid-1990s and the mid-2000s, the number of APRNs per capita grew an average of more than
nine percent annually, compared with just one percent for primary care physicians.27 Given that
APRNs play a key role in filling the gap between demand and supply for health care services,
any unnecessary restrictions on APRNs are likely to exacerbate access problems and thereby
harm some of the most vulnerable patients.28
There are currently 1,454 APRNs licensed in West Virginia, of which approximately
1,000 are primary care nurse practitioners. APRNs live in 49 of West Virginia’s 55 counties and
practice in 54 of the state’s 55 counties, which suggests that greater utilization of West Virginia’s
APRNs could improve access to care.29 Moreover, some reports suggest more APRNs practice in
states that allow independent practice (i.e., practice without immediate supervision or
collaborative agreement requirements).30 As the West Virginia legislature noted, “[a]dvanced
practice nursing scope of practice is increasingly expanding in other states, including the border
state of Maryland, thus decreasing the likelihood of keeping the best advanced practice nurses in
46
West Virginia.” 31 Thus, if West Virginia were to eliminate the requirement for a collaborative
agreement for prescriptive authority, it might prevent the loss of APRNs to less restrictive states
and might benefit from growth in the number of APRNs choosing to practice there.
In sum, unnecessary restrictions on APRNs may result in decreased access to health care
services, with potentially harmful consequences for West Virginia patients.
b. Removing Restrictions Would Likely Lower Costs and Increase Consumer
Options
Removing the requirement that APRNs have a collaborative agreement with a physician
in order to prescribe medications is likely to reduce the cost of basic health care services and
could spur innovation in health care delivery and widen the range of choices available to
consumers. APRN care is generally less expensive to patients and payers than physician care,
and is often provided in a variety of health care delivery settings.32 Similar to the situation in
other states, there is anecdotal evidence suggesting some West Virginia APRNs who wish to set
up a practice that is separate from a physician or other health care entity (e.g., they are not
employees) must pay physicians to enter a collaborative agreement for prescriptive authority.33
Unless these arrangements involve true and beneficial supervision, 34 they raise the possibility
that APRNs are not compensating physicians for their time, but rather for the potential loss of
income some physicians believe may occur as a result of APRNs’ entry into the primary care
marketplace. Such payments raise the costs of practice, likely resulting in fewer independently
practicing APRNs and higher prices (without any improvement in the quality of care provided).
It is also our understanding that some APRNs who are attempting to establish an
independent practice find it difficult to identify a physician willing to enter into a collaborative
47
prescribing agreement at all.35 Other APRNs find it difficult to develop a sustainable business
because collaborating physicians can revoke collaborative agreements at any time for any reason,
which compromises APRNs’ ability to treat their patients.36 For example, if an APRN’s
collaboration agreement for prescriptive authority with a physician ends, the APRN could
continue to see patients, but could not continue to prescribe needed medications, compromising
their ability to meet the needs of their patients.
APRNs have also played an important role in the development of alternative settings for
care delivery, such as retail clinics. Retail clinics typically are located within larger retail stores,
staffed by APRNs, and offer consumers a convenient way to obtain basic medical care at
[competitive prices.37 Retail clinics generally offer weekend and evening hours, which provide
greater flexibility for patients,38 and appear to provide competitive incentives for other types of
physician practices to offer extended hours as well.39 If the West Virginia legislature decides to
relax restrictions on APRNs’ ability to prescribe medications, such action might increase both
the number and types of care settings available to West Virginia consumers.40
c. Legislative Consideration of Health and Safety Issues
As previously noted, certain professional licensure requirements are necessary to protect
patients. It is unclear, however, whether the current West Virginia collaboration requirement
provides any additional patient protection.41 Moreover, the IOM, based on an extensive review of
the studies and literature on the safety of APRNs as primary care providers, has recommended
that nurses be permitted by state licensing laws to practice to the full extent of their education
and training.42 The IOM noted some “states have kept pace with the evolution of the health care
system by changing their scope-of-practice regulations to allow NPs to see patients and prescribe
48
medications without a physician’s supervision or collaboration,” and that sixteen states and the
District of Columbia allow APRNs to practice and prescribe independently.43 The IOM further
stated that “[n]o studies suggest that care is better in states that have more restrictive scope-of
practice regulations for APRNs than in those that do not.”44
V. CONCLUSION
Removing the requirement that APRNs who want to prescribe medications have a
collaborative agreement with a physician has the potential to benefit consumers by expanding
choices for patients, containing costs, and improving access. Maintaining an unnecessary and
burdensome requirement is likely to deprive consumers of the benefits that increased competition
can provide. Accordingly, we encourage the West Virginia legislature to carefully review the
safety record of APRNs in West Virginia and to consider whether the current requirement is
necessary to assure patient safety in light of the almost twenty years of prescribing experience of
West Virginia APRNs, as well as the findings of the Institute of Medicine. Absent countervailing
safety concerns regarding APRN prescribing practices, removing the collaborative agreement for
prescriptive authority appears to be a procompetitive improvement in the law that would benefit
West Virginia health care consumers.
Respectfully submitted,
Andrew I. Gavil, Director
Office of Policy Planning
Richard A. Feinstein, Director
49
Bureau of Competition
Howard Shelanski, Director
Bureau of Economics
_____________________________
1. This staff testimony expresses the views of the Federal Trade Commission’s Office of Policy
Planning, Bureau of Competition, and Bureau of Economics. The testimony does not necessarily
represent the views of the Federal Trade Commission or of any individual Commissioner. The
Commission, however, has voted to authorize staff to submit this testimony.
50
2. The Institute of Medicine (IOM) and others use the term APRN to include nurse practitioners,
certified nurse midwives, certified registered nurse anesthetists, and clinical nurse specialists.
West Virginia law was recently amended to replace the term “advanced nurse practitioner” with
“advanced practice registered nurse.” See Senate Bill No. 572, amending W.VA. CODE § 30-71. To simplify the foregoing discussion, our testimony uses the term APRN, but our comments
focus on the statutory restrictions and evidence related specifically to APRNs who provide
primary care services, previously referred to in West Virginia laws and regulations as “advanced
nurse practitioners” or ANPs. Certified Nurse Midwives (“CNMs”) in West Virginia currently
must have a collaborative agreement in place to practice, treat, and prescribe medications. To the
extent that CNMs provide primary care for women, including gynecological exams and
prescriptions, it is possible the same reasoning for removing restrictions on nurse practitioners
could apply to this aspect of CNMs’ practice. Certified Registered Nurse Anesthetists
(“CRNAs”) in West Virginia can only practice under the supervision of a physician; our
testimony does not address CRNA supervision requirements.
3. Letter from The Hon. Daniel Foster, The Senate of West Virginia, to the Office of Policy
Planning, Bureau of Economics, and Bureau of Competition, Federal Trade Commission (May 3,
2012) [hereinafter Letter from Sen. Foster].
4. Letter from Sen. Foster; West Virginia Senate Concurrent Resolution No. 93, available at
http://www.legis.state.wv.us/Bill Text HTML/2012 SESSIONS/RS/Bills/scr93%20intr.htm
5. See INSTITUTE OF MEDICINE, THE FUTURE OF NURSING: LEADING CHANGE,
ADVANCING HEALTH, available at http://www.iom.edu/Reports/2010/The-Future-ofNursing-Leading-Change-Advancing-Health.aspx [hereinafter IOM NURSING REPORT] at 45, 9-15, 29-30 (2011) (discussing need for federal and state actions “to update and
standardize scope-of-practice regulations to take advantage of the full capacity and education of
APRNs”); id. at 10 (recommending specifically state legislatures “[r]eform scope-of-practice
regulations to conform to the National Council of State Boards of Nursing Model Nursing
Practice Act and Model Nursing Administrative Rules”).
6. Letter from Sen. Foster.
7. See generally IOM NURSING REPORT, supra note 5.
8. Id. at 4. See also id. at 85-161, 98-99 (discussing nursing scope-of-practice issues and quality
of care, including numerous quality of care studies); About the Institute of Medicine, available at
http://www.iom.edu/About- IOM.aspx
9. See discussion infra at Section IV.a. and notes 23-25 and accompanying text (discussing
primary care provider shortages and the number of West Virginians who could gain health care
coverage over the next few years as a result of the Affordable Care Act).
51
10. Federal Trade Commission Act, 15 U.S.C. § 45.
11. Standard Oil Co. v. Fed. Tr. Comm’n, 340 U.S. 231, 248 (1951) (“The heart of our national
economic policy long has been faith in the value of competition.”).
12. See FTC, An Overview of FTC Antitrust Actions in Health Care Services and Products (June
2012), available at http://www.ftc.gov/bc/healthcare/antitrust/hcupdate.pdf ; FTC, Competition
in the Health Care Marketplace: Formal Commission Actions (1996 – 2008), available at
http://www.ftc.gov/bc/healthcare/antitrust/commissionactions.htm.
13. See FTC & U.S. DEP’T OF JUSTICE (“DOJ”), IMPROVING HEALTH CARE: A DOSE
OF COMPETITION (2004), available at
http://www.ftc.gov/reports/healthcare/040723healthcarerpt.pdf [hereinafter FTC & DOJ,
IMPROVING HEALTH CARE].
14. FTC and staff advocacy may comprise letters or comments addressing specific policy issues,
Commission or staff testimony before legislative or regulatory bodies, amicus briefs, or reports.
See, e.g., FTC Staff Letter to The Hon. Stephen LaRoque, North Carolina House of
Representatives (May 2012) (regarding the regulation of dental service organizations and the
business organization of dental practices), available at
http://www.ftc.gov/os/2012/05/1205ncdental.pdf ; FTC and DOJ Written Testimony before the
Illinois Task Force on Health Planning Reform Concerning Illinois Certificate of Need Laws
(Sept. 2008), available at http://www.ftc.gov/os/2008/09/V080018illconlaws.pdf ; FTC Amicus
Curiae Brief in In re Ciprofloxacin Hydrochloride Antitrust Litigation Concerning Drug Patent
Settlements Before the Court of Appeals for the Federal Circuit (Case No. 2008-1097) (Jan.
2008), available at http://www.ftc.gov/os/2008/01/080129cipro.pdf; FTC & DOJ, IMPROVING
HEALTH CARE supra note 13.
15. FTC Staff Letter to The Hon. Thomas P. Willmott and The Hon. Patrick C. Williams,
Louisiana House of Representatives, Concerning the Likely Competitive Impact of Louisiana
House Bill 951 Concerning Advanced Practice Registered Nurses (Apr. 2012), available at
http://www.ftc.gov/os/2012/04/120425louisianastaffcomment.pdf; FTC Staff Letter to The Hon.
Paul Hornback, Senator, Commonwealth of Kentucky State Senate Concerning Kentucky Senate
Bill 187 and the Regulation of Advanced Practice Registered Nurses (Mar. 2012), available at
http://www.ftc.gov/os/2012/03/120326ky staffletter.pdf; FTC Staff Letter to The Hon. Rodney
Ellis and The Hon. Royce West, the Senate of the State of Texas, Concerning Texas Senate Bills
1260 and 1339 and the Regulation of Advanced Practice Registered Nurses (May 2011),
available at http://www.ftc.gov/os/2011/05/V110007texasaprn.pdf; FTC Staff Letter to The Hon.
Daphne Campbell, Florida House of Representatives, Concerning Florida House Bill 4103 and
the Regulation of Advanced Registered Nurse Practitioners (Mar. 2011), available at http://www
ftc.gov/os/2011/03/V110004campbell-florida.pdf;
16. Although West Virginia law was recently revised to use the term “Advanced Practice
Registered Nurse,” more broadly, the law continues to specify separate requirements, including
52
supervision by a physician, for Certified Nurse-Midwives (W.VA. CODE §§ 30-15-1 – 8) and
Certified Registered Nurse Anesthetists (W.VA. CODE § 30-7-15).
17. W.VA. CODE § 30-7-1, as amended by Senate Bill 572 (2012). See also W.VA. CODE R.
§ 19-7-2 (Title 19, Legislative Rule, Board of Registered Professional Nurses, Series 7:
Announcement of Advanced Practice Registered Nurse) and proposed revisions, recently filed
with the West Virginia Secretary of State and the Legislative Rulemaking Review Committee at
http://apps.sos.wv.gov/adlaw/csr/readfile.aspx?DocId=24012&Format=PDF. See explanation of
Legislative Rules, infra, note 18.
18. W.VA. CODE R. §§ 19-7-1 to 4. According to the West Virginia Secretary of State’s
website, “[l]egislative rules are proposed by an agency subject to the Administrative Procedure
Act (APA), but must be approved by the Legislature before they go into effect, unless they are
filed as Emergency rules. A legislative rule is the only form of rule under the APA which: carries
the force of law, or supplies a basis of civil or criminal liability, or grants or denies a specific
benefit.” STATE OF WEST VIRGINIA, WEST VIRGINIA SECRETARY OF STATE,
ADMINISTRATIVE LAW, RULE MAKING, TYPES OF RULES,
http://www.sos.wv.gov/administrative-law/rulemaking/Pages/types.aspx (last visited Sept. 6,
2012). See also W.VA. CODE §29A-3-11 (explaining that a proposed rule must be submitted by
the state agency to the legislative rulemaking review committee, which has the following options
after reviewing the legislative rule: “the committee shall recommend that the Legislature: (1)
Authorize the promulgation of the legislative rule; or (2) Authorize the promulgation of part of
the legislative rule; or (3) Authorize the promulgation of the legislative rule with certain
amendments; or (4) Recommend that the proposed rule be withdrawn.”).
19. See W.VA. CODE §§ 30-7-15a –c, as amended by Senate Bill 535 (2012) (the law as
amended maintains the collaborative agreement and other related requirements, but allows
APRNs to prescribe medications for chronic conditions other than chronic pain for up to one
year (prior regulations limited most prescriptions to a six-month supply or less) and to prescribe
anticoagulants (prior law prohibited such prescriptions)); W.VA. CODE R. §§ 19-8-1
to 6 (Title 19, Legislative Rule, Board of Registered Professional Nurses, Series 8: Limited
Prescriptive Authority for Nurses in Advanced Practice) and proposed revisions, recently filed
with the West Virginia Secretary of State and the Legislative Rulemaking Review Committee at
http://apps.sos.wv.gov/adlaw/csr/readfile.aspx?DocId=24006&Format=PDF. See also West
Virginia Board of Examiners for Registered Professional Nurses, instructions for collaborative
agreements for prescriptive authority, available at
http://www.wvrnboard.com/images/initial%20application%20for%20prescriptive%20authority.p
df (the APRN must certify that the collaborative agreement includes: 1) agreed upon written
guidelines or protocols; 2) statements describing the individual and shared responsibilities of the
APRN and the physician; 3) provision for the periodic and joint evaluation of the prescriptive
practice; and 4) provision for the periodic and joint review and updating of the written guidelines
or protocols).
20. IOM FUTURE OF NURSING REPORT, supra note 5, at 158, Table 3-A1.
53
21. See Kaiser Commission on Medicaid and the Uninsured, Improving Access to Adult Primary
Care in Medicaid: Exploring the Potential Role of Nurse Practitioners and Physician Assistants,
at 1 (Mar. 2011) (noting by 2020 the U.S. will face an estimated shortage of 91,000 physicians,
with a projected shortfall of approximately 45,000 primary care physicians and 46,000
specialists), available at http://www kff.org/medicaid/upload/8167.pdf [hereinafter “Kaiser
Commission, Improving Access”]; the Association of American Medical Colleges (AAMC)
Physician Shortages Factsheet, available at
https://www.aamc.org/download/150584/data/physician shortages factsheet.pdf (in its
projections of physician supply and demand, the AAMC assumes that each additional two NPs
(or Physicians Assistants) reduce physician demand by one) [hereinafter “AAMC, Physician
Shortages”]; U.S. DEP’T OF HEALTH & HUMAN SERVS., HEALTH RESOURCES &
SERVS. ADMIN. BUREAU OF HEALTH PROFESSIONS, THE PHYSICIAN
WORKFORCE: PROJECTIONS AND RESEARCH INTO CURRENT ISSUES AFFECTING
SUPPLY AND DEMAND [hereinafter HRSA PHYSICIAN WORKFORCE
REPORT] 70-72, exhibits 51-52 (2008), available at
http://bhpr.hrsa.gov/healthworkforce/reports/physwfissues.pdf; Annie Lowrey & Robert Pear,
Doctor Shortage Likely to Worsen With Health Law, NY TIMES (July 28, 2012), available at
http://www.nytimes.com/2012/07/29/health/policy/too-few-doctors-in-many-uscommunities.html.
22. See Kaiser Commission, Improving Access, supra note 21, at 1; Leighton Ku et al., The
States’ Next Challenge –Securing Primary Care for Expanded Medicaid Populations, 364 N.
ENGL. J. MED. 493, 494 (2011).
23. West Virginia Senate Concurrent Resolution No. 93, available at
http://www.legis.state.wv.us/Bill Text HTML/2012 SESSIONS/RS/Bills/scr93%20intr.htm.
24. U.S. Dep’t of Health & Human Servs., Health Resources & Servs. Admin., Find Shortage
Areas by State and County, available at http://hpsafind.hrsa.gov/HPSASearch.aspx (last visited
July 27, 2012).
25. West Virginians for Affordable Care, The Affordable Care Act: Moving Forward in West
Virginia, at 4 (Apr. 2011), available at http://www.wvahc.org/downloads/ACA-Moving Forward
in WV041611.pdf.See also Jennifer Sullivan and Kathleen Stoll, Lower Taxes, Lower Premiums:
The New Health Insurance Tax Credit in West Virginia, Families USA (Sept. 2010), available at
http://www familiesusa.org/assets/pdfs/health-reform/premiumtax-credits/West-Virginia.pdf;
John Holahan and Irene Headen, Medicaid Coverage and Spending in Health
Reform: National and State-by-State Results for Adults at or Below 133% FPL, Kaiser
Commission on Medicaid and the Uninsured (May 2010), available at http://www
kff.org/healthreform/upload/Medicaid-Coverage-and-Spending-in-Health-Reform-National-andState-By-State-Results-for-Adults-at-or-Below-133-FPL.pdf. It is unclear what impact, if any,
the U.S. Supreme Court’s recent decision on the Medicaid provisions of the ACA will have on
West Virginia’s decisions with respect to expanding Medicaid. See generally National
54
Federation of Independent Business v. Sebelius, No. 11–393 (U.S. Sup. Ct. June 28, 2012).
26. Kaiser Commission, Improving Access, supra note 21, at 3. The statistics for West Virginia
suggest that APRNs could be especially helpful for addressing access issues. For example,
approximately 43% of the population resides in non-metropolitan areas, compared to an average
of 16% of the U.S. population (Kaiser Family Foundation, State Health Facts: West Virginia,
Population Distribution by Metropolitan Status, available at
http://www.statehealthfacts.org/profileind.jsp?ind=18&cat=1&rgn=50). “21.6% of West
Virginia’s adults aged 18 - 64 lacked any kind of health care coverage, compared with a national
average of 18.2%;” and approximately “17.2% of West Virginia’s population lives below the
poverty level, compared with 13.2% of the national population.” WEST VIRGINIA
DEPARTMENT OF HEALTH & HUMAN RESOURCES, ADVOCATING FOR CHRONIC
DISEASE MANAGEMENT AND PREVENTION at 6, 4 (May 2011), available at
http://www.wvcancer.com/Portals/9/Chronic%20Disease%20Strategic%20Plan%202011.pdf.
27. See Kaiser Commission, Improving Access, supra note 21, at 3; AAMC, Physician
Shortages, supra note 21.
28. See generally AARP & Robert Wood Johnson Foundation, Center to Champion Nursing in
America, Access to Care and Advanced Practice Nurses: A Review of Southern U.S. Practice
Laws (2010), available at http://championnursing.org/resources/access-care-and-advancedpractice-nurses-review-southern-us-practice-laws (policy paper discussing restrictions on APRN
practice in 11 southern states (not including West Virginia), including the impact on access and
consumers and advocating the removal of state restrictions on APRNs’ practice, including the
removal of restrictions on prescriptive authority).
29. West Virginia Board of Examiners for Registered Professional Nurses, ANNUAL REPORT
OF THE BIENNIUM, July 1, 2009 – June 30, 2011, at pp. 84-85, 90-91, 100-101, available at
http://www.legis.state.wv.us/legisdocs/reports/agency/R02 FY 2011 1330.pdf
30. See, e.g., TEXAS LEGISLATIVE BUDGET BOARD STAFF, TEXAS STATE
GOVERNMENT EFFECTIVENESS AND EFFICIENCY: SELECTED ISSUES AND
RECOMMENDATIONS 297, 300 (Jan. 2011) (submitted to the 82nd Texas Legislature) (stating
the number of advanced practice nurses is lower in states with restrictive regulatory
environments, and these restrictions may “limit the expansion of retail clinics, which generally
employ APRNs to provide a limited range [of] primary healthcare”) [hereinafter TEXAS
BUDGET BOARD STAFF REPORT]; Julie A. Fairman et al., Perspective: Broadening the
Scope of Nursing Practice, 364 N. ENGL. J. MED. 193, 194 (2011) (noting “nurses tend to
move from more restrictive to less restrictive states . . . with a resulting loss of access to care
for patients”).
31. West Virginia Senate Concurrent Resolution No. 93, available at
http://www.legis.state.wv.us/Bill Text HTML/2012 SESSIONS/RS/Bills/scr93%20intr htm.
55
32. See Joanne M. Pohl et al., Unleashing Nurse Practitioners’ Potential to Deliver Primary
Care and Lead Teams, 29 HEALTH AFFAIRS 900, 901 (2010), available at http://content
healthaffairs.org/content/29/5/900 full.pdf+html. (noting APRNs and physicians assistants are
underutilized “despite being qualified to provide primary care at a lower cost than other
providers”).
33. FTC staff discussions with representatives of organizations that represent APRNs in West
Virginia indicated one APRN pays a collaborating physician approximately $20,000 per year
based on a percentage of the APRN’s monthly revenue and another pays the physician an hourly
rate for the collaboration. Although the West Virginia Center for Nursing website at
http://www.wvcenterfornursing.org/pdf/WVStateDataSnapshotARNs.pdf provides data
suggesting a large percentage of APRNs in West Virginia have prescriptive authority, it is our
understanding from our discussions that most of these APRNs work as employees of physicians
or other health care institutions. Anecdotal evidence from other states suggests APRNs pay
significant fees to collaborating physicians. See, e.g., Letter from The Hon. Paul Hornback,
Commonwealth of Kentucky State Senate, to Susan DeSanti, Director, Office of Policy Planning,
Federal Trade Commission (Jan. 18, 2012) (noting in “some cases, the physicians are charging a
considerable amount of money monthly or annually to sign a CAPA [the collaborative
prescribing agreement], although they essentially perform no services for the fee”); Letter from
The Hon. Thomas P. Willmott and The Hon. Patrick C. Williams, Louisiana House of
Representatives, to Susan S. DeSanti, Director, Office of Policy Planning, Federal Trade
Commission (Jan. 18, 2012), (noting that APRNs in Louisiana often must pay 10-45% of their
collected fees to physicians for entering into collaborative practice agreements).
34. See discussion in Section III supra.
35. See discussion in note 36 infra. See also Letter from Sen. Foster (noting the “WV Board of
Medicine has promulgated collaborative agreement guidelines with additional recommended
restrictions”); West Virginia Board of Medicine, guidelines for collaborative agreements,
available at http://www.wvbom.wv.gov/collnurse.pdf.
36. See, e.g., WEST VIRGINIA NURSE, Vol.15, No. 3 at p. 9 (Aug., Sept., Oct. 2012), West
Virginians Denied Access to Chronic Care Due to Bogus Warning to Physicians, available at
http://www.aldpub.com/West Virginia/West Virginia.pdf. The article noted that one nurse
practitioner (Toni DiChiacchio) had to halt plans to open a chronic disease management clinic
because the “collaborating physician, who was interested in the services the clinic could provide,
was “spooked” by not only his malpractice insurance company but the WV Board of Medicine,”
which incorrectly told the physician that he would have a greater risk of malpractice by
collaborating with a nurse practitioner. The President of the WV Nurses Association stated this
was not an isolated case and that: “These warnings and increasingly restrictive guidelines from
the BOM to WV physicians make it harder for APRNs to get an agreement signed. Without an
agreement, needed services like Toni’s clinic must close their doors. We are very concerned for
our patients. There is already a shortage of providers and WV is losing APRNs to neighboring
states that realize collaborative agreements are unnecessary. Research proves advanced practice
56
registered nurses provide high quality, safe care.” See also W.VA. CODE §§ 55- 7B-1 to 12
(dealing with medical malpractice and professional liability and stating in § 55-7B-9 that “a
health care provider may not be held vicariously liable for the acts of a nonemployee pursuant to
a theory of ostensible agency unless the alleged agent does not maintain professional liability
insurance covering the medical injury which is the subject of the action in the aggregate amount
of at least one million dollars”).
37. See Robin Weinick, et al., Policy Implications of the Use of Retail Clinics at 12 (2010) (Rand
Health Technical Report prepared for the U.S. Dept. of Health and Human Serv.), at
http://www.rand.org/content/dam/rand/pubs/technical reports/2010/RAND TR810.pdf
[hereinafter Rand, Policy Implications of the Use of Retail Clinics] (also noting the services
offered at retail clinics are generally narrower in scope than those provided by urgent care
centers and emergency rooms); Ateev Mehrotra et al., Retail Clinics, Primary Care Physicians,
and Emergency Departments: A Comparison of Patients Visits, 27 HEALTH AFFAIRS
1272, 1279 (2008). See generally William M. Sage, Might the Fact that 90% of Americans Live
Within 15 Miles of a Wal-Mart Help Achieve Universal Health Care?, 55 U. Kan. L. Rev. 1233,
1238 (2007) (describing the size and scope of retail clinics); Mary Kay Scott, Scott & Company,
Health Care in the Express Lane: Retail Clinics Go Mainstream, at 22 (Sept. 2007) (report
prepared for the California HealthCare Foundation), available at
http://www.chcf.org/publications.
Evidence indicates that the quality of care provided by APRNs in retail clinics is “similar
to that provided in physician offices and urgent care centers and slightly superior to that of
emergency departments.” Ateev Mehrotra et al., Comparing Costs and Quality of Care at Retail
Clinics with that of Other Medical Settings for 3 Common Illnesses, 151 ANNALS INTERNAL
MED. 321, 326 (2009) (analyzing 14 quality metrics for commonly treated ailments, including
ear, strep, and urinary tract infections, and finding “[f]or most measures, quality scores of
retail clinics were equal to or higher than those of other care settings”).
38. Cf. Rena Rudavsky, Craig Evan Pollack, & Ateev Mehrotra, The Geographic Distribution,
Ownership, Prices, and Scope of Practice at Retail Clinics, 151 ANNALS INTERNAL MED.
315, 317 (2009) (“In a random sample of 98 [limited service] clinics, all had weekday and
weekend hours and 95 (97%) had evening hours (after 6 p m.) on weekdays.”).
39. See Rand, Policy Implications of the Use of Retail Clinics at 13, supra note 37 (according to
many medical community representatives interviewed for this report, including a representative
of the American Medical Association, “retail clinics have stimulated physicians to adopt evening
and weekend hours”).
40. See, e.g., TEXAS BUDGET BOARD STAFF REPORT, supra note 30, at 300 (noting
restrictions on APRNs’ scope of practice may limit both the number and types of retail clinics
available to Texas consumers); MARY TAKACH & KATHY WITGERT, NATIONAL
ACADEMY FOR STATE HEALTH POLICY, ANALYSIS OF STATE REGULATIONS AND
POLICIES GOVERNING THE OPERATION AND LICENSURE OF RETAIL CLINICS 6
57
(Feb. 2009) (noting “the most powerful state regulatory tools affecting [retail clinics’] operations
are the scope of practice regulations that govern nurse practitioners and other non-physician
medical personnel”).
41. See discussion in Section III supra at note 20 and accompanying text.
42. IOM NURSING REPORT, supra note 5 at 85-161; see especially id. at 98 (with respect to
many primary care services, “the contention that APRNs are less able than physicians to deliver
care that is safe, effective, and efficient is not supported by the decades of research that has
examined this question”) (internal citations omitted).
43. IOM NURSING REPORT, supra note 5 at 98.
44. Id. at 99. See also Julie A. Fairman et al., Perspective: Broadening the Scope of Nursing
Practice, 364 N. ENGL. J. MED. 193, 194 (2011) (stating “[t]here are no data to suggest that
nurse practitioners in states that impose greater restrictions on their practice provide safer and
better care than those in less restrictive states or that the role of the physician has changed or
deteriorated”).
58
Appendix B
West Virginia Counties in Health Professional Shortage Areas
County not part of a HPSA
Whole county is designated as HPSA
Part of county designated as HPSA
Source: Bureau of Health Professions, HHS Data accessed from the Area Resource File Health
Resources and Services Administration, HHS. Retrieved from www.rupri.org/profiles/westvirginia2.pdf.
59
Appendix C
Distribution of Birthing Services in WV
There is no federal designation for maternity-specific health professional shortage areas. Approximately
11,000 women in West Virginia have greater than a 30-minute drive to a birthing facility. A less than 30-minute
drive to a birthing facility is standard for best outcomes. Retrieved from http://www.wvperinatal.org/shortage.htm.
60
APPENDIX D
THE PROVISIONS OF THE CODE OF ETHICS FOR NURSES
1. The nurse, in all professional relationships, practices with compassion and
respect for the inherent dignity, worth and uniqueness of every individual,
unrestricted by considerations of social or economic status, personal attributes, or
the nature of health problems.
2. The nurse's primary commitment is to the patient, whether an individual,
family, group, or community.
3. The nurse promotes, advocates for, and strives to protect the health, safety,
and rights of the patient.
4. The nurse is responsible and accountable for individual nursing practice and
determines the appropriate delegation of tasks consistent with the nurse's
obligation to provide optimum patient care.
5. The nurse owes the same duties to self as to others, including the
responsibility to preserve integrity and safety, to maintain competence, and to
continue personal and professional growth.
6. The nurse participates in establishing, maintaining, and improving healthcare
environments and conditions of employment conducive to the provision of
quality health care and consistent with the values of the profession through
individual and collective action.
7. The nurse participates in the advancement of the profession through
contributions to practice, education, administration, and knowledge
development.
8. The nurse collaborates with other health professionals and the public in
promoting community, national, and international efforts to meet health needs.
9. The profession of nursing, as represented by associations and their members,
is responsible for articulating nursing values, for maintaining the integrity of
the profession and its practice, and for shaping social policy.
61
Appendix E
State By State Comparison of Practice Maps and Grids
Major Components of the Consensus Model by State Updated 04/2013 red= score for
maps
S=supervised C= written collaborative *C= collaborative not written NS= not specified
Board
APRN
Title
Roles
License
Education
Certification
Indep. Practice
C C
R N
N M
A
Alabama
12
Alaska
13
APN
0
ANP,
RNA
0
4
RNA,
ANP
(include
s CNM)
Approva
l to
practice
0
4
Authoriz
ation to
practice
CNS not
in act
4 S
C
0
0
C
N
S
CNP
N
S
0
0
American
Samoa
7
Arizona
18
0
3 0
1
4
CNP
N
S
C
0
N
S
0
C 0
0
1
0
1
C
N
S
C
1
0
APRN Insuff info
sep from
RN
Insuff info
C
C
0
0
3
4
C
N
S
0
3
4
Certifica
tion
C C
R N
N M
A
No CNS
cert
0
3
NA, NM,
NP
Indep. Prescribing
4
S
0
N
S
0
C
C
4 0
0
1
4 1
4
N
S
C
N
S
0
0
0
0
C
0
1 0
S
0
0
N
S
C
0
1
0
0
Arkansas
22
California
14
Colorado
20
4
4
4
4
APN
0
4
APRN
sep from
RN 4
Certifica
te to
practice
0
AP
registry
0
4
4
4
CRNA
only
1
C
C
C
C
1
1 0
0
0
0
C
0
N
S
0
C
0
N
S
0
C
0
N
S
0
C
0
1
1
1 1
1
1
1
62
Board
APRN
Title
Connecti
cut 20
4
Delaware
16
APN
0
District of
Columbia
24
Florida
11
Roles
License
4
4
4
4
ARNP
CNM,
CNP,
CRNA
0
3
Georgia
16
4
Guam
20
4
4
4
APRN
sep from
RN
4
4
Certifica
te,
APRN
sep from
RN
0
Certifica
tion,
APRN
sep from
RN
0
Authoriz
ation to
practice
APRN
sep from
RN 0
4
Education
Certification
Indep. Practice
C C
R N
N M
A
C
N
S
CNP
S
C
C
4 0
0
C
4
4
Indep. Prescribing
C C
R N
N M
A
C
N
S
C
S
C
C
C
0
0
0
0
0
0
C
C
C
C
C
C
C
4 0
0
0
0
0
0
0
0
4 1
1
1
1 1
1
1
1
C
C
N
S
C
C
N
S
C
C
0
0
0
0
0
0
S
C
C
C
S
C
C
C
4
4 0
0
0
0
0
0
0
0
C
0
C
0
C
0
C
4
C
0
C
0
C
0
C
0
1
1
1
4
4
4
4
CNP
0
0
0
Hawaii
24
4
4
Recogni
tion,
APRN
sep from
RN
0
4
4 1
1
1
1 1
Idaho
28
63
Board
APRN
Title
Roles
License
Education
Certification
4
4
4
C C
R N
N M
A
4 1 1
0
4
4
4
4 0
APN
CNS,
CNM,
CNP 3
Register
for
prescript
0
NP req
degree or
cert
3
4
APN
Illinois
16
Indiana
8
0
ARNP
Iowa
20
Indep. Practice
0
CRNA,
CNM
2
Register
ed
4
4
C
N
S
C
C
0
S
0
Indep. Prescribing
C C
R N
N M
A
1
1
1
C
N
S
1
1
C
0
C
0
C
0
C
0
C
0
C
0
C
C
C
S
C
C
C
0
0
0
0
0
0
0
C C
* *
C
*
C*
1
1
C* C C* C*
*
1
1
1
1
C
0
C
0
C
0
1
1
4
0
CNP
CNP
1
1
Kansas
17
4
4
4
4
Not req
0
Kentucky
24
4
4
4
4
4
Louisiana
20
4
1
C
0
C
0
C
0
1
1
N
S
0
C
0
C
0
C
0
C
0
C
C
C S
C
C
C
0
0
0
0
0
0
C
er
t
1 as
N
P
1
1
S
4
Maine
25
4
4
4
Approva
l to
practice
(lic)
4
4
0
S
4
4 0
1
1
1
4
0
C
e
r
t
a
s
0
N
P
0
Maryland
17
4
CRNA,
NM,
Nurse
Psychoth
erapist,
CRNP,
CNS
Certifica
tion
APRN
sep from
RN
4
C
C
4 0
0
C
1
N
S
0
C
N
S
C
0
0
0
0
64
Board
APRN
Title
Roles
License
Education
Certification
Indep. Practice
C C
R N
N M
A
C
N
S
CNP
S
C
Indep. Prescribing
C C
R N
N M
A
C
N
S
CNP
C
S
C
C
0
4
Massach
usetts
4
4
18
Michigan
12
Nse
Spec
0
Authoriz
ation to
practice
in an
advance
d role 0
Certifica
tion
4
4
4
4 0
1
0
0
0
1
0
0
N
S
N
S
N
S
NS
N
S
N
S
N
S
NS
0
0
0
0
0
0
C
C
0
C
0
C
0
C
C
0
C
0
C
0
CRNA, C C
CNM, 0 0
CNP 3
C
0
C
0
C
0
C
0
C
0
C
0
C
0
C
0
C
0
C
0
0
Minnesot
a 12
Mississip
pi 14
Missouri
16
Montana
28
Nebraska
23
Nevada
12
4
4
4
CRNA,
CNM,
CNP 3
4
4
4
Certifica
te of
recogniti
on 0
Docume
nt of
recogniti
on 0
No degree
specified 0
4
4 0
C
4
4 0
C
0
0
0
N
S
0
C
0
4
4
4 1
1
1
1 1
1
1
1
4
4
4
4
C
0
1
C
0
C
0
C
0
4
Certifica
tion 0
4
4
C
0
C
0
C
0
N
S
0
C
0
CRNA,
CNM,
CNP
CRNA,
CNM,
CNP
CRNA,
CNM,
CNP
CRNA,
CNM,
CNP
3
3
3
3
4
Certifica
tion 1
1
1
3
21
New
Jersey
13
CRNA,
CNM,
CNS,
NP 4
APN 0
New
Hampshir
e
4
APRN
registry
0
0
4
APN 0
C
0
4
4
C
C
0
C
0
0
1
1
N
S
0
1
1
1
N
S
0
1
S
0
C
0
C
0
C
0
N
S
0
C
0
C
0
C
0
65
Board
APRN
Title
Roles
License
Education
Certification
Indep. Practice
C C
R N
N M
A
New
Mexico 28
New York
8
North
Carolina
14
North
Dakota
28
Northern
Mariana
Islands
28
Ohio
16
Oklahom
a 23
Oregon
22
4
4
NP
0
CNM,
NP
2
No
term
0
4
4
4
4
4
4
ARPN
4
4
No
term
No
term
6
18
4
CNM, NP
2
4 1
C C
R N
N M
A
C
N
S
CNP
1
1
1 1
1
1
1
CNM, NP N C
2 S 0
N
S
0
C
0
N
S
0
C
0
N
S
0
C
0
C
N
S
C
N
S
C
0
C
4
4 1
0
1
0
0
0
4
4 1
1
0
0
1 1
1
1
1
4
Grad
degree or
cert
4
Grad
degree or
cert
1
1
1
1
1
1
1
1
S
C
C
C
S
C
C
C
4
4 0
0
0
0
0
0
0
0
S
S
4
4
4 0
1
1
1 0
0
S
0
S
0
4
4
4 0
1
1
1 0
1
1
1
Board
Certifica
tion
CNS,
CRNP
N
N
S
N
S
C
N
S
N
S
N
S
C
0
0
0
0
0
Certifica
te of
authority
to
practice
0
4
S
CNM
consider
ed CNP
4
CNS,
CRNP
0
Rhode
Island
Approval
to
practice
0
4
CNP
1
0
Pennsylv
ania
4
CNM
BOH
4
Certifica
te
2
C
N
S
Indep. Prescribing
CNS, S
CRNP
2
2
0
RNP,
CRNA
CNM
thru
BOH
4
0
0
0
2
APN
0
2
C
4
4 0
C
1
1
1
1
C
C
0
0
0
66
Board
South
Carolina
20
South
Dakota
APRN
Title
4
Roles
License
4
No
term
0
Tennesse
e 12
Texas
20
APN
0
4
4
4
Vermont
28
Virgin
Islands
20
Virginia
14
4
4
4
LNP
0
Washingt
on 21
West
Virginia
21
ARNP
3
APRN,
APRNCRNA
4
4
4
CRNA,
CNM,
NP
3
CRNA,
CNM,
NP
3
4
4
C C
R N
N M
A
C
N
S
CNP
C
Indep. Prescribing
C C
R N
N M
A
C
N
S
CNP
C
0
C
0
C
0
C
0
C
0
C
0
C
0
CNS,
CNM.
CNP
CNM,
CNS,
CNP
C
C
C
C
N
S
C
N
S
C
4 0
0
0
0
3
3
Do not
maintain
RN
4
4
Do not
maintain
RN 4
C
0
C
0
C
0
C
0
C
0
C
0
4 C C
0
C
0
C
0
C
0
C
0
C
0
C
0
1
1
1 1
1
1
1
0
4
4
1
4
4 1
1
1
1 1
1
1
1
C
C
C
C
C
C
0
0
0
0
0
0
N
S
S
N
S
S
N
S
S
C
0
0
C
C
4 0
4
0
S
4 0
4
CRNA, CRNA,
CNM, CNM, NP
NP
3
3
CNM,
ANP
4
0
0
C
0
4 0
4
CNS are
regist
3
0
0
C
Certifica
te
0
4
CNM sep
Board
APN
or
ANP
Indep. Practice
4 0
4
Utah
28
Certification
4
Do not
maintain
RN
4
4
14
Education
CRNA,
CNM, NP
3 1
0
1
1 1
N
S
0
0
0
4
4
N
S
1
0
C
0
0
N
S
S
CNM,
CNS,
ANP
0
0
1
0
S
C
1 0
0
N
S
C
0
0
67
Board
Wisconsi
n 19
Wyoming
24
APRN
Title
Roles
License
Education
Certification
Indep. Practice
C C
R N
N M
A
C
N
S
CNP
1
APNP
0
4
4
4
4 1
C
0
1
4
4
Recogni
tion 0
4
4
1
1
Indep. Prescribing
C C
R N
N M
A
C
N
S
CNP
C
0
C
0
C
0
C
0
1 1
1
1
1
1
S=supervised C= written collaborative *C= collaborative not written NS= not specified
This does not represent all elements of Consensus but, rather, the major selected elements of role
recognition, licensure, education, certification, independent practice, and independent
prescribing in each of the four recognized roles.
The numbers on the grid are our way of quantifying the extent to which any given state
has implemented the major elements of the consensus model. This does not represent all
elements of consensus but, rather, the major elements of role recognition, licensure, education,
certification, independent practice, and independent prescribing in each of the recognized roles.
The major elements of the consensus model are listed along the top of the grid. For each element,
we allocate up to 4 points depending on whether the state has laws addressing this consensus
requirement for each of the 4 roles (CRNA, CNM, CNS, CNP). For example, West Virginia has
4 points under the “Education” column because your state require a graduate degree or post
graduate certificate for each of the 4 roles (CRNA, CNM, CNS, CNP), which is consistent with
the consensus model. Under the Independent Practice and Independent Prescribing columns, the
roles are broken out by sub-column. In these cells, you will see a number as well as a letter (S, C,
NS, or *C). These letters indicate the scope of practice for each of the four roles, whether the
role must practice under supervision (S), under a written collaborative agreement (C), under a
(non-written) collaborative arrangement (*C), or if the nature of the scope of practice is
unspecified in law (NS). Under the “Board” Column, you will see the total number of points for
each state. (NCSBN)
68
Mid-Level Practitioners Authorization by State
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 which he/she practices, to dispense a controlled substance in the course of professional practice.
Examples of mid-level practitioners include, but are not limited to, health care providers such as nurse practitioners, nurse midwives,
nurse anesthetists, clinical nurse specialists and physician assistants who are authorized to dispense controlled substances by the
state in which they practice.
AMB
AS
DOM
ET
HMD
MP
ND
NH
NP
OD
PA
RPH
Ambulance Service
Animal Shelters
Doctors of Oriental Medicine
Euthanasia Technicians
Homeopathic Physician
Medical Psychologists
Naturopathic Physician
Nursing Homes
Nurse Practitioners
Optometrists
Physician Assistants
Registered Pharmacists
Table Description
The table represents the controlled substances authority for Mid-level Practitioner's by discipline within the state of which they
practice. It indicates the categories of Mid-Level Practitioners by State and the licensing authority granted to each category
within that particular State through the Drug Enforcement Administration (DEA). If authority is granted, specific schedules are
listed along with any special instructions like administer only, dispense only or order only. It may also indicate if the DEA is
reviewing a new law to see if it is in fact consistent with the issuance of a DEA registration for controlled substances. If
authority is NOT granted for a particular category, a "NO" will be indicated. The Drugs and drug products that come under the
Controlled Substances Act are divided into five schedules. Some examples in each schedule are outlined below.
Schedule I substances (1)
The substances in this schedule are those that have no accepted medical use in the United States and have a high abuse
potential. Some examples are heroin, marihuana, LSD, MDMA, peyote.
Schedule II substances (2)
The substances in this schedule have a high abuse potential with severe psychic or physical dependence liability. Schedule II
controlled substances consist of certain narcotic, stimulant and depressant drugs. Some examples of Schedule II narcotic
controlled substances are: opium, morphine, codeine, hydromorphone (Dilaudid), methadone, pantopon, meperidine
(Demerol).
Schedule III substances (3)
The substances listed in this schedule have an abuse potential less than those in Schedules I and II, and include compounds
containing limited quantities of certain narcotic drugs and non-narcotic drugs such as: condeine (Tylenol with Codeine),
derivatives of babituric acid except those listed in another schedule, nalorphine, benzphetamine, chlorphentermine, clortemine,
phendimetrazine, paregoric and any compound, mixture, preparation or suppository dosage form containing amobarbital,
secobarbital or pentobarbital.
Schedule IV substances (4)
The substances in this schedule have an abuse potential less than those listed in Schedule III and include such drugs as:
barbital, phenobarbital, chloral hydtrate, clorazepate (Tranxene), alprazolam (Xanax), Quazepam (Dormalin).
Schedule V substances (5)
The substances in this schedule have an abuse potential less than those listed in Schedule IV and consist primarily of
preparations containing limited quantities of certain narcotic and stimulant drugs generally for antitussive, antidiarrheal and
analgesic purposes. Some examples are buprenorphine and propylhexedrine.
Table Key
2, 2N, 3, 3N, 4, 5
Rx's
CRNA
CNM
Per formulary
Schedule categories
Prescriptions
Certified Registered Nurse Anesthetists
Certified Nurse Midwives
Per the directives written out by the state licensing board.
NO
NO
NO
2N & 3N
Line 1 Animal
Shelter Line 2
ET'S Name
2N & 3N Only
Law Enforcement
or City Animal
Shelter
2N & 3N Sodium
Pentobarbital &
Sodium
Pentobarbital
W/Lidocaine
Line 1 Animal
Shelter Line 2
ET'S Name
2N & 3N Sodium
Pentobarbital &
Sodium
Pentobarbital
W/Lidocaine
Line 1 Animal
Shelter Line 2
ET's Name
AS
Wednesday, January 09, 2013
NO
California
NO
Arkansas
Arizona
Alaska
NO
Alabama
AMB
NO
NO
NO
NO
NO
DOM
2N FOR Sodium
Pentobarital
ONLY
Line 1 RVT Line
2 Shelter
NO
NO
2N & 3N
Administer Only
2N & 3N
Administer Only
ET
NO
NO
2, 2N, 3, 3N, 4, 5
Prescribe,
Dispense,
Administer
NO
NO
HMD
NO
NO
NO
NO
NO
MP
3, 3N, 4 & 5
Prescribe Only
NO
2, 2N, 3, 3N, 4, 5
Prescribe,
Dispense,
Administer
NO
NO
ND
NO
NO
NO
NO
NO
NH
2, 2N, 3, 3N, 4, 5
Prescribe,
Dispense,
Administer
NOTE: 2
Requires
Continuing
Education
3, 3N, 4 & 5
Prescribe, Order,
Administer
2, 2N, 3, 3N, 4, 5
2, 2N, 3, 3N, 4, 5
NO
NP
3, 3N
3, 3N, 4, 5
3, 3N Prescribe,
Dispense,
Administer
Prescribe 3, 4, 5
3, 3N, 4, 5
Administer &
Prescribe
OD
PA
2, 2N, 3, 3N, 4, 5
Prescribe,
Dispense,
Administer
3, 3N, 4 & 5
Prescribe, Order,
Administer
2, 2N, 3, 3N, 4, 5
2, 2N Administer,
Dispense, Order
& Prescribe
3, 3N 4, & 5 RX'S
ONLY
3, 3N, 4, 5
Prescribe
MID LEVEL PRACTITIONERS - Controlled Substance Authority by Discipline within State
Page 1 of 11
2, 2N, 3, 3N, 4, 5
Prescribe Only
NO
NO
NO
NO
RPH
AS
DOM
ET
NO
NO
NO
2, 2N, 3, 3N, 4, 5
NO
2N & 3N Only
Law Enforcement
or City Animal
Shelter
District of Columbia
NO
Delaware
NO
Connecticut
2, 2N, 3, 3N, 4, 5
Line 1 AMB Line
2 DR's Name
Colorado
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
CNMI - Commonwealth of the Northern Mariana Islands
AMB
NO
NO
NO
NO
NO
HMD
NO
NO
NO
NO
NO
MP
NO
NO
NO
NO
NO
ND
NO
NO
NO
NO
NO
NH
2, 2N, 3, 3N, 4, 5
Prescribe Only
2, 2N, 3, 3N, 4, 5
Prescribe Only
2, 2N, 3, 3N, 4, 5
2, 2N, 3, 3N, 4, 5
NO
NP
NO
NO
2, 2N, 3, 3N, 4, 5
3, 3N, 4 & 5
NO
OD
2, 2N, 3, 3N, 4, 5
Prescribe,
Dispense &
Procure
2, 2N, 3, 3N, 4, 5
Prescribe Only
2, 2N, 3, 3N, 4, 5
2, 2N, 3, 3N, 4, 5
3, 3N, 4, 5
Special Request
for 2, 2N
PA
Page 2 of 11
NO
NO
NO
NO
NO
RPH
NO
2N, 3, 3N, 4
Administer &
Procure Only
NO
2N & 3N
NO
2N, 3N, Sodium
Pentobarbital &
Sodium
Pentobarbital
w/Lidocaine
AS
Idaho
2, 2N, 3, 3N, 4, 5
LINE 2 DR'S
NAME
Hawaii
NO
Guam (TT)
NO
NO
Georgia
Florida
AMB
NO
NO
NO
NO
NO
DOM
NO
NO
2N & 3N
NO
NO
ET
NO
NO
NO
NO
NO
HMD
NO
NO
NO
NO
NO
MP
NO
NO
NO
NO
NO
ND
NO
2, 2N, 3, 3N, 4, 5
NO
NO
NO
NH
2, 2N, 3, 3N, 4, 5
YES
Administer &
Prescribe 2-5
APRN's can
Prescribe
2, 2N, 3, 3N, 4, 5
3, 3N, 4, 5
NO
NP
2, 2N, 3, 3N, 4, 5
NO
NO
3, 3N, 4
NO
OD
2, 2N, 3, 3N, 4, 5
Prescribe Only
3, 3N, 4 & 5
Prescribe,
Dispense,
Administer
May Write Orders
for Inpatients for
2-5
4 & 5 Only
Prescribe,
Dispense &
Administer
3, 3N, 4 & 5
Prescribe Only
NO
PA
Page 3 of 11
NO
Under Review
NO
NO
NO
NO
RPH
NO
NO
NO
2N & 3N
Line 1 Animal
Shelter Line 2
ET'S Name
NO
2, 2N, 3, 3N
2N & 3N Sodium
Pentobarital,
Telazol, Ketamine
2N & 3N Line 1
Animal Shelter
Line 2 ET'S Name
AS
NO
Kentucky
2, 2N, 3, 3N, 4, 5
Kansas
Iowa
Indiana
Illinois
AMB
NO
NO
NO
NO
NO
DOM
NO
NO
NO
NO
NO
ET
NO
NO
NO
NO
NO
HMD
NO
NO
NO
NO
NO
MP
NO
NO
NO
NO
NO
ND
NO
NO
2, 2N, 3, 3N, 4, 5
NO
NO
NH
2, 2N, 3, 3N, 4, 5
Prescribe Only
2, 2N, 3, 3N, 4, 5
2, 2N, 3, 3N, 4, 5
2, 2N, 3, 3N, 4, 5
2N, 3, 3N, 4, 5
Prescribe,
Dispense &
Administer Only
Prescribe 30 day
supply for
schedule 2
NP
3, 3N, 4, 5
2, 2N, 3, 3N, 4, 5
2, 2N, 3, 3N, 4, 5
NO
3, 4, 5 Prescribe
OD
NO
2, 2N, 3, 3N, 4, 5
2, 2N, 3, 3N, 4, 5
NO 2 Stimulants
or Depressants
3, 3N, 4, 5
Under review for
2 & 2N
2N, 3, 3N, 4, 5
Prescribe,
Dispense &
Administer Only
Prescribe 30 day
supply for
schedule 2
PA
Page 4 of 11
NO
NO
NO
NO
NO
RPH
NO
2N & 3N
Administer,
Dispense &
Procure for
Sodium
Pentobarbital
NO
2, 2N, 3, 3N, 4,
5 Procure &
Administer
Sodium
Pentobarbital
2N
2, 2N, 3, 3N
Administer,
Dispense &
Procure
Line 1 Animal
Shelter Line 2
ET'S Name
AS
NO
Michigan
NO
Massachusetts
NO
Maryland
Maine
NO
Louisiana
AMB
NO
NO
NO
NO
NO
DOM
NO
NO
NO
NO
NO
ET
NO
NO
NO
NO
NO
HMD
NO
NO
NO
NO
2, 2N, 3, 3N, 4 &
5 Prescribe Only
MP
NO
NO
NO
NO
NO
ND
NO
NO
NO
NO
NO
NH
2, 2N, 3, 3N, 4, 5
Prescribe
No CDS required
2 requires a letter
2, 2N, 3, 3N, 4, 5
Administer,
Prescribe &
Procure Only
2, 2N, 3, 3N, 4 &
5
2, 2N, 3, 3N, 4, 5
Procure
3, 3N, 4, 5
2, 2N Prescribe
& Dispense for
Attention Deficit
Disorder Only
NP
2, 2N, 3, 3N, 4, 5
Prescribe &
Administer
2, 2N, 3, 3N, 4,
5
Prescribe & (not
all PA's can
Procure)
Dispense, Only,
2 Requires a
Letter
3, 3N, 4, 5
Prescribe Only
PA
3, 3N, 4, 5
2, 2N, 3, 3N, 4, 5
Prescribe
No CDS required
2 requires a letter
NO Under Review 2, 2N, 3, 3N, 4, 5
Administer,
Prescribe &
Procure Only
NO
3, 3N, 4, 5
3, 3N, 4, 5
Prescribe,
Administer
OD
Page 5 of 11
NO
2,2N,3,3N,4, 5
Prescribe only
Institutional
pharmacist only,
No Retail
NO
NO
NO
RPH
NO
2, 2N, 3, 3N, 4, 5
NO
NO
NO
AS
2, 2N, 3, 3N, 4, 5
Nebraska
2, 2N, 3, 3N, 4, 5
Montana
2, 2N, 3, 3N, 4, 5
Missouri
NO
Mississippi
NO
Minnesota
AMB
NO
NO
NO
NO
NO
DOM
NO
2, 2N, 3, 3N, 4, 5
Administer Only
NO
NO
NO
ET
NO
NO
NO
NO
NO
HMD
NO
NO
NO
NO
NO
MP
NO
2, 3, 3N
NO
NO
NO
ND
NO
NO
2, 2N, 3, 3N, 4, 5
NO
NO
NH
CNM's 2, 2N 72
Hour Supply,
3, 3N, 4, 5
Prescribe Only
2, 2N, 3, 3N, 4, 5
48 Hour Supply
Only
3, 3N, 4, 5
APRN's
Administer,
Dispense &
Prescribe
CS RX license &
BNDD & prof
license needed
2, 2N, 3, 3N, 4, 5
2, 2N, 3, 3N, 4, 5
NP
2, 2N, 3, 3N, 4, 5
2, 2N, 3, 3N, 4, 5
2, 2N, 3, 3N, 4, 5
4 & 5 Prescribe
4&5
OD
2, 2N - 72 Hour
Supply,
3, 3N, 4, 5
Prescribe Only
3, 3N, 4, 5
34 day Supply
Only for
2 & 2N
3, 3N, 4, 5
Administer,
Dispense &
Prescribe 3 for a
5 day supply only
CS RX license &
BNDD & prof
license needed
2, 2N, 3, 3N, 4, 5
2, 2N, 3, 3N, 4, 5
PA
Page 6 of 11
NO
2, 2N, 3, 3N, 4, 5
Administer,
Procure,
Dispense &
Prescribe
(Pharmacy
Practice
Agreement)
NO
NO
NO
RPH
NO
2N, 3N Sodium
Pentobarital
2, 2N, 3, 3N, 4,
5 Only Law
Enforcement or
City Animal
Shelter
2N Administer,
Dispense &
Procure for
Sodium
Pentobarbital
NO
2, 2N, 3, 3N, 4, 5
AS
NO
New York
2, 2N, 3, 3N, 4, 5
New Mexico
NO
New Jersey
NO
New Hampshire
Nevada
AMB
NO
3N for
Testosterone
Only
NO
NO
NO
DOM
NO
2N & 3N
NO
NO
2N Administer
ONLY
ET
NO
NO
NO
NO
2, 2N, 3, 3N, 4, 5
HMD
NO
2, 2N, 3N, 4, 5
Prescribe,
Administer
NO
NO
NO
MP
NO
NO
NO
3, 4 Prescribe
Only
NO
ND
NO
NO
NO
NO
NO
NH
2, 2N, 3, 3N, 4, 5
Also Nurse
Midwives
2, 2N, 3, 3N, 4, 5
ALSO CNM's &
CRNAs Under
review
Testosterone
2, 2N, 3, 3N, 4, 5
Prescribe
2, 2N, 3, 3N, 4,
5 From
Formulary
Procure
2, 2N, 3, 3N, 4, 5
Prescribe,
Dispense,
Administer
NP
NO
3, 3N, 4, 5
3, 3N, 4, 5
Prescribe
3, 3N, 4
Prescribe,
Dispense
2, 2N, 3, 3N, 4,
5 Prescribe &
Administer Only
OD
2, 2N, 3, 3N, 4, 5
RX'S Only
2, 2N, 3, 3N, 4, 5
Prescribe
Procure &
Dispense
2, 2N, 3, 3N, 4, 5
Prescribe
2, 2N, 3, 3N, 4, 5
Procure
2, 2N, 3, 3N, 4, 5
Prescribe,
Dispense,
Administer
PA
Page 7 of 11
NO
2, 2N, 3, 3N, 4, 5
Administer &
Prescribe
NO
NO
NO
RPH
NO
2, 2N, 3, 3N, 4, 5
NO
2N, 3, 3N
NO
2, 2N, 3, 3N
AS
Oregon
2, 2N, 3, 3N, 4, 5
Line 2 DR'S
Name
Oklahoma
2, 2N, 3, 3N, 4, 5
Ohio
NO
North Dakota
2, 2N, 3, 3N, 4, 5
Line 2 DR'S
Name
North Carolina
AMB
NO
NO
NO
NO
NO
DOM
NO
2, 2N, 3, 3N, 4 &
5
NO
NO
NO
ET
NO
NO
NO
NO
NO
HMD
NO
NO
NO
NO
NO
MP
2, 2N, 3, 3N, & 5
Prescribe,
4 Only Per
Formulary
NO
NO
NO
NO
ND
NO
NO
NO
NO
2, 2N, 3, 3N, 4, 5
NH
2, 2N, 3, 3N, 4, 5
CNS's 2-5
Prescribe only
per formulary
3, 3N, 4, 5
EXCEPT
CRNA'S
Administer
Only, 2, 2N, 3,
3N, 4, 5
2, 2N, 3, 3N, 4, 5
Prescribe &
Dispense
2, 2N, 3, 3N, 4, 5
APRN'S 2-5
2, 2N, 3, 3N, 4, 5
May Not Order
CS's
NP
3, 3N, 4 & 5
Analgesics Per
Formulary No
Ordering
3, 3N, 4, 5
3 Prescribe
3
2, 2N, 3, 3N, 4, 5
OD
2, 2N, 3, 3N, 4, 5
2, 2N, 3, 3N, 4, 5
Prescribe &
Administer Only
3, 3N, 4, 5
Prescribe
2, 2N, 3, 3N, 4, 5
Prescribe
2, 2N, 3, 3N, 4,
5 Prescribe Only
30 Day Supply
for 2-3N
PA
Page 8 of 11
NO
NO
NO
3, 3N, 4, 5
Prescribe Only
2, 2N, 3, 3N, 4, 5
Prescribe,
Procure, &
Dispense
RPH
NO
3N
NO
2N, 3N
NO
AS
2, 2N, 3, 3N, 4, 5
South Dakota
2&4
South Carolina
NO
Rhode Island
NO
Puerto Rico
NO
Pennsylvania
AMB
NO
NO
NO
NO
NO
DOM
NO
NO
NO
NO
NO
ET
NO
NO
NO
NO
NO
HMD
NO
NO
NO
NO
NO
MP
NO
NO
NO
NO
NO
ND
NO
NO
NO
NO
NO
NH
NP & CNM 2,
2N, 3, 3N, 4, 5
3, 3N, 4 & 5
Prescribe Only
CNM & NP 2, 2N,
3, 3N, 4, 5,
CNS 2, 2N &4
Procure
NO
2, 2N, 72 Hour
Supply,
3, 3N, 4, 5 30
Day Supply
Prescribe Only
NP
2, 2N, 3, 3N, 4, 5
3, 3N, 4 & 5
3, 3N, 4 & 5
Prescribe
NO
3, 4 and 5 Use
of Drugs In
Practice Is Not
To Exceed 6
Weeks
OD
2, 2N, 3, 3N, 4, 5
3, 3N, 4, 5
2, 2N, 3, 3N, 4, 5
Can't Procure
NO
2, 2N, 3, 3N, 4, 5
Special
Addendum
PA
Page 9 of 11
NO
NO
NO
NO
NO
RPH
NO
NO
2, 2N
2, 2N, 3, 3N, 4, 5
Only Law
Enforcement or
City Animal
Shelter
Line 2 DVM Name
2N, 3N For
Sodium
Pentobarbital
2N FOR Sodium
Pentobarital
AS
NO
Virgin Islands
NO
Vermont
Utah
2, 2N, 3, 3N, 4 &
5
Texas
2, 2N, 3, 3N, 4, 5
Line 1 AMB Line
2 Medical Director
Tennessee
AMB
NO
NO
NO
NO
NO
DOM
NO
NO
NO
NO
NO
ET
NO
NO
NO
NO
NO
HMD
NO
NO
NO
NO
NO
MP
NO
Prescribe 2, 3,
3N, 4, 5
Testosterone,
Codeine,
Codeine
combination
products &
Carisoprodol only
3N Administer &
Prescribe Only
NO
NO
ND
NO
NO
NO
NO
NO
NH
4, 5 Prescribe &
Dispense Only
2, 2N, 3, 3N, 4, 5
Procure
2, 2N, 3, 3N, 4, 5
Per Formulary
No More Than 20
Doses
3, 3N, 4, 5
Prescribe &
Administer 30
Day Supply Only
2, 2N, 3, 3N, 4 ,5
Prescribe,
Dispense,
Administer
NP
PA
NO
3, 4, 5
Prescribe
Under review 2
and 2N
4&5 3
Prescribe &
Administer
Only No More
Than 72 Hours
Dose
2 Administer
Only
3, 3N, 4, 5
Prescribe &
Administer
NO
2, 2N, 3, 3N, 4 &
5 RX from State
Formulary
2, 2N, 3, 3N, 4 , 5
Prescribe &
Administer Only
3, 3N, 4, 5
Prescribe &
Administer 30
Day Supply Only
2, 2N, 3, 3N, 4 , 5 2, 2N, 3, 3N, 4, 5
Prescribe &
Dispense
OD
Page 10 of 11
NO
NO
NO
NO
NO
RPH
2, 2N, 3, 3N, 4,
5 Only Law
Enforcement
Line 2 DVM
2N & 3N
2N Only for
Sodium
Pentobarital
Line 1 Shelter
Line 2 ET's Name
2N Sodium
Pentobarital
2, 2N, 3, 3N
AS
NO
Wyoming
NO
Wisconsin
2, 2N, 3, 3N, 4 &
5
West Virginia
NO
Washington
2, 2N, 3, 3N, 4 &
5
Virginia
AMB
NO
NO
NO
NO
NO
DOM
2, 2N, 3, 3N, 4, 5
Pentobarbital Based Drugs
NO
NO
NO
NO
ET
NO
NO
NO
NO
NO
HMD
NO
NO
NO
NO
NO
MP
NO
NO
NO
3, 3N 4, 5
NO
ND
NO
NO
NO
NO
NO
NH
2, 2N, 3, 3N, 4, 5
2, 2N, 3, 3N, 4 &
5
3, 3N, 4 & 5
2, 2N, 3, 3N, 4 &
5
2, 2N, 3, 3N, 4, 5
NP
3, 3N, 4 & 5
3, 3N, 4 & 5
3, 3N, 4, 5
3, 3N, 4 & 5
3, 3N, 4
Analgesics Only
OD
2, 2N, 3, 3N, 4,
5 RX's ONLY
2, 2N, 3, 3N, 4 &
5
3, 3N, 4 & 5 RX's
Only
Allopathic RX's 2,
2N, 3, 3N, 4 & 5,
Osteopathic
RX 2, 2N, 3, 3N,
4&5
2, 2N, 3, 3N, 4, 5
PA
Page 11 of 11
NO
NO
NO
2, 2N, 3, 3N, 4 &
5 Prescribe Only
NO
RPH
State Regulatory
and
Prescriptive Authority
2012
American Academy
of
Nurse Practitioners
©American Academy of Nurse Practitioners, 2012
NURSE PRACTITIONER
PRESCRIPTIVE AUTHORITY
*
*
$
*
*
*
*
*
*
*
*
*
*
*
* *
*
**
**
+
*
*
*
*
*
*
**
**
**
*
**
*
*
+
States That Prescribe Legend Drugs Only
States Recognized by DEA with Authority to Prescribe Controlled Substances
*
Schedule II-V Only
**
Schedule III-V Only
***
Schedule V Only
Schedule II Limitations
+
Pending DEA Approval
Source: Drug Enforcement Administration, DEA 2011
American Academy of Nurse Practitioners, 2012
Last Updated 8-12-11
The American Academy of Nurse Practitioners is the largest full service Nurse Practitioner organization representing the 148,000 Nurse Practitioners in all Specialties
COLLABORATION/SUPERVISORY LANGUAGE IN STATE
PRACTICE ACTS & REGULATIONS FOR NURSE PRACTITIONERS
$
$
+
++
++
++
+
+
+
+
+
+
*
Plenary Authority (No Physician Relationship Required)
Collaboration with Physician
General Supervision/Delegation by Physician
+ Collaboration or Supervision for Prescribing Only
++ Collaboration for Prescribing Schedule II Drugs Only
+++ Other
 Pending
Source: State Nurse State Practice Acts
And Administration Rules, 2009
Update: 8/9/11
NURSE PRACTITIONER AUTHORITY TO
SIGN HANDICAP PARKING PERMITS
States Where Nurse Practitioner Can Sign Handicap Placard Forms
States Where Nurse Practitioner Cannot Sign Handicap Placard
Source: State Statutes
Update: 8/11
STATE MEDICAID COVERAGE MAP
(REIMBURSEMENT RATE)
WA
^
ME
ND
MT
MN
VT
NH
OR
ID
WI
SD
MA
NY
MI
WY
RI
NE
CA
NV
*
PA
IA
IL
OH
IN
*
UT
WV
CO
+
CT
VA
MO
KS
NJ
DE
KY
DC
NC
MD
TN
OK
AZ
AR
NM
SC
MS
AL
GA
LA
TX
FL
AK
HI
100% of Physician Fee
90-95% of Physician Fee
*
w/max per day dependent on setting
+
rural NPs may be paid higher fees
^
w/fixed rate per visit to NP clinics
Other
Update: July 2011
NURSE PRACTITIONER’S AUTHORITY
TO ORDER PHYSICAL THERAPY
$
$
*
Accept NP Referrals or No Referral Required
Refer Medical Condition to Physician/ Evaluation or Limited Self-Referred Treatment
Physician Referral Required
Other
Source: State Physical Therapy Acts and Regulations, 2007
American Physical Therapy Association, 2007
 American Academy of Nurse Practitioners 2012
Update: 8/11
STATE RECOGNITION OF NURSE PRACTITIONERS
AS PRIMARY CARE PROVIDERS
$
$
*
Identified in Statute and/or Administrative Code
Implied in Statute
Not defined in Statute
Other
Source: Nurse Practice Acts & Regulations
National Conference of State Legislations, March 2000
Update: 8/11
Nurse Practitioners Authority to
Sign Death Certificates
Nurse Practitioners Can Sign Death Certificates
Licensed Physician Only
Other
+
Pending
©American Academy of Nurse Practitioners, 2012
Update: 4/12
Nurse Practitioner Authority to
Sign Workers’ Compensation Claims
States Where Nurse Practitioner Can Sign Workers’ Compensation Forms
States Where Nurse Practitioner Cannot Sign Workers’ Compensation Forms
States Where Nurse Practitioner Can Sign Workers’ Compensation Forms if Delegated
by Physician
Source: State Nurse Practice Acts
Updated 8/11
NPA and SBON R&R
NPA and SBON R&R
NPA and SBON R&R
NPA and SBON R&R
NPA
Alabama
Alaska
Arizona
Arkansas
California
January 2013
PRIMARY SOURCE/
AUTHORITY FOR
RECOGNITION
STATE
―The board shall issue a certificate to practice nurse anesthesia to
any person who qualifies under this article and is licensed pursuant
CRNAs are a type of "advanced practice registered nurse."
―A license to practice as an advanced practice nurse may be
issued…[b]y application [or]…[b]y endorsement.‖ [Nurse Practice
Act of the State of Arkansas, sec. 17-87-302(b)]
CRNAs are a type of ―advanced practice nurse.‖
The Board of Nursing will ―certify‖ a registered nurse as a certified
registered nurse anesthetist if the registered nurse meets the
requirements set forth in the statute. [Arizona Revised Statutes sec.
32-1634.03]
The SBON R&R sets forth the requirements a ―registered nurse
anesthetist‖ needs for initial authorization. [Professional
Regulations, ch. 44, art. 5, sec. 12 AAC 44.500]
"The Board of Nursing may grant approval for advanced practice
nursing as certified registered nurse anesthetists to applicants who
meet the requirements of [Board of Nursing rules]." [Alabama Board
of Nursing Administrative Code, sec. 610-X-9-.03(1)]
"The nurse anesthetist . . . is licensed by the Board of Nursing...."
[Alabama Nurse Practice Act, sec. 34-21-81(4)(c)]
Advanced practice nurses are "certified by the Board of Nursing to
engage in the practice of advanced practice nursing." [Alabama
Nurse Practice Act, sec. 34-21-81(3)]
TYPE OF RECOGNITION
STATUTORY/REGULATORY NURSE ANESTHETIST RECOGNITION
NPA and SBON R&R
NPA and SBON R&R
NPA and SBON R&R
NPA and SBON R&R
NPA and SBON R&R
Colorado
Connecticut
Delaware
District of
Columbia
Florida
January 2013
Page 2
PRIMARY SOURCE/
AUTHORITY FOR
RECOGNITION
STATE
―When the Board finds that an applicant has complied with the
CRNAs are a type of ―advanced registered nurse practitioner.‖
―Only a person currently licensed as a registered nurse under
Chapter 54 of this title shall be eligible to apply for a certificate to
practice nurse-anesthesia under this chapter." [DCMR, Title 17, ch.
57, sec. 5701.1]
CRNAs are a type of ―advanced practice registered nurse.‖
Advanced practice nurses may be issued a license in their specific
area of specialization. [Delaware Board of Nursing Rules and
Regulations, sec. 8.9.4]
The department of public health may issue an advanced practice
registered nurse license to a registered nurse who holds and
maintains current certification as a nurse anesthetist from the AANA
and who meets additional educational requirements. [General
Statutes of Connecticut, ch. 378, sec. 20-94(a)]
―The board shall establish the advanced practice registry and shall
require that a nurse applying for registration identify such nurse‘s
area of specialty.‖ [Colorado Nurse Practice Act, sec. 12-38111.5(3)]
to the provisions of this chapter.‖ [California Nursing Practice Act,
ch. 6, art. 7, sec. 2830]
TYPE OF RECOGNITION
NPA and SBON R&R
NPA and SBON R&R
NPA and SBON R&R
NPA and SBON R&R
NPA
Georgia
Hawaii
Idaho
Illinois
Indiana
January 2013
Page 3
PRIMARY SOURCE/
AUTHORITY FOR
RECOGNITION
STATE
Indiana does not specify a specific method or process by which it
A person shall be qualified for licensure as an advanced practice
nurse if that person meets the requirements set forth by the Illinois
NPA. [Illinois Nurse Practice Act, 225 ILCS 65/65-5]
In order to qualify for a license to practice advanced practice
registered nursing in Idaho, a person must meet certain criteria
established by Idaho‘s NPA. [Idaho Nursing Practice Act, sec. 541409]
Advanced practice registered nurses are granted recognition by the
Hawaii board of nursing if they meet certain qualifications. [Hawaii
Revised Statutes, ch. 457, sec. 457-8.5]
In order to receive authorization to practice as a CRNA in Georgia,
a person must meet certain criteria established by Georgia‘s SBON
R&R [Rules and Regulations of the Georgia Board of Nursing, sec.
410-12-.04(3)]
requirements…it shall certify the applicant to the [Florida]
Department [of Health] which shall issue the applicant an Advanced
Registered Nurse Practitioner certificate in the specialty category
which is consistent with the applicant‘s educational preparation or
specialty designation.‖ [Florida SBON R&R, sec. 64B9-4.002(3)]
TYPE OF RECOGNITION
SBON R&R
NPA and SBON R&R
NPA and SBON R&R
Iowa
Kansas
Kentucky
January 2013
Page 4
PRIMARY SOURCE/
AUTHORITY FOR
RECOGNITION
STATE
―An applicant for licensure to practice as an advanced practice
registered nurse shall file with the board a written application for
licensure ….‖ [Kentucky Nursing Practice Act, sec. KRS 314.042(1)]
―Upon application to the board by any licensed professional nurse in
this state and upon satisfaction of the standards and requirements
established under this act…the board shall grant an authorization to
the applicant to perform the duties of a registered nurse anesthetist
and be licensed as an advanced practice registered nurse.‖
[Kansas Stat. Ann., sec. 65-1154]
Also included within the Iowa Administrative Code are references to
ARNP licensure. For example, ―The board may restrict, suspend
or revoke a license to practice as an advanced registered nurse
practitioner….‖ [Iowa Admin. Code, sec. 655—7.2(11)(152)]
―A registered nurse who has completed all requirements to practice
as an advanced registered nurse practitioner and who is registered
with the board to practice shall use the title advanced registered
nurse practitioner (ARNP)." [Iowa Admin. Code, sec. 655—
7.2(2)(152)]
authorizes nurse anesthetists to practice.
TYPE OF RECOGNITION
NPA and SBON R&R
NPA and SBON R&R
NPA and SBON R&R
SBON R&R
NPA and SBON R&R
Louisiana
Maine
Maryland
Massachusetts
Michigan
January 2013
Page 5
PRIMARY SOURCE/
AUTHORITY FOR
RECOGNITION
STATE
A specialty certification for a nurse anesthetist will be granted to a
registered nurse who satisfies the requirements set forth in the
Michigan NPA and Michigan SBON R&R. [Board of Nursing Admin.
Rules, part 4, sec. R338.10404(1)]
―When the Board [of Registration in Nursing] determines that an
applicant for authorization meets the qualifications set forth…the
Board will endorse the applicant‘s license as a registered nurse with
a designation authorizing the applicant to practice in an expanded
role in the appropriate area of practice.‖ [Code of Massachusetts
Regulations, 244 CMR 4.15(2)]
CRNAs are a type of ―nurse authorized to practice in the expanded
role.‖
CRNAs are a type of "advanced practice nurse."
―An applicant for certification as a nurse anesthetist shall [lists
requirements] ….‖ [Code of Maryland Regulations, Title 10, subtitle
27, ch. 06.02]
―‘Advanced practice registered nurse‘ means an individual who is
currently licensed … to practice advanced practice registered
nursing…‖ [Maine Statutes, Title 32, ch. 31, subch. 1, sec. 2102 (5A)]
Advanced practice registered nurses must meet certain
requirements in order to obtain a license to practice in Louisiana.
[Louisiana Revised Statutes, sec. 920]
TYPE OF RECOGNITION
NPA and SBON R&R
NPA and SBON R&R
NPA and SBON R&R
Minnesota
Mississippi
Missouri
January 2013
Page 6
PRIMARY SOURCE/
AUTHORITY FOR
RECOGNITION
STATE
― ‗Advanced practice registered nurse,‘ a nurse who has education
beyond the basic nursing education and is certified by a nationally
recognized professional organization as a certified nurse
practitioner, certified nurse midwife, certified registered nurse
anesthetist, or a certified clinical nurse specialist. The board shall
CRNAs who meet certain educational requirements set forth by the
SBON R&R will be ―certified‖ to practice in Mississippi. [Rules and
Regulations of the Mississippi Board of Nursing, ch. IV(2)]
―The Minnesota Board of Nursing must maintain a record of all
registered nurses with a current Minnesota license who are certified
as advanced practice registered nurses. Advanced practice
registered nurses are required to notify the Board each time they are
issued a current certificate from a national nurse certification
organization acceptable to the Board. In order that an advanced
practice registered nurse‘s (APRN) name be placed on the
Minnesota Board of Nursing registry, an APRN must send the
Board a copy of a current certificate issued by a national nurse
certification organization which meets the criteria established by the
Board. One of the grounds for disciplinary action by the Board is
failure by an advanced practice registered nurse to notify the Board
of certification status as a clinical nurse specialist, nurse anesthetist,
nurse-midwife, or nurse practitioner.‖
The Minnesota Board of Nursing Web site indicates that:
TYPE OF RECOGNITION
NPA and SBON R&R
NPA and SBON R&R
NPA and SBON R&R
Montana
Nebraska
Nevada
January 2013
Page 7
PRIMARY SOURCE/
AUTHORITY FOR
RECOGNITION
STATE
―If the board finds that the applicant has met all the appropriate
requirements set forth in [the Nevada SBON R&R], he will be issued
An applicant for initial approval as a CRNA must meet specified
educational and administrative requirements. [Nevada Admin.
Code, sec. 632.515]
―An applicant for a license under the Advanced Practice Registered
Nurse Licensure Act to practice as a certified registered nurse
anesthetist shall‖ meet specified educational and administrative
requirements. [Nebraska Revised Statutes, Section 71-1730(1)]
―‘Advanced practice registered nurse‘ … means a registered nurse
licensed by the board to practice as an advanced practice
registered nurse pursuant to 37-8-202, MCA, and ARM
24.159.1414.‖ Admin. Rules of Montana, ch. 8, sec. 8.32.305 et
seq.]
Nurse anesthetists who meet certain educational requirements set
forth by the Missouri SBON R&R will be recognized by the board
and will be eligible to practice as advanced practice nurses. [Rules
of Department of Economic Development, sec. 20 CSR 22004.100(2)(A)]
promulgate rules specifying which nationally recognized professional
organization certifications are to be recognized for the purposes of
this section. Advanced practice nurses and only such individuals
may use the title ‗Advanced Practice Registered Nurse‘ and the
abbreviation ‗APRN‘....‖ MO Rev. Stat. 335.016(2)
TYPE OF RECOGNITION
NPA and SBON R&R
NPA and SBON R&R
NPA and SBON R&R
DOH
SBON R&R
New Hampshire
New Jersey
New Mexico
New York
North Carolina
January 2013
Page 8
PRIMARY SOURCE/
AUTHORITY FOR
RECOGNITION
STATE
The North Carolina Board of Nursing requires CRNAs to obtain
―recognition‖ to practice. In accordance with G.S. 90-171.21(d)(4)
and 21 NCAC 36.0226, a nurse anesthetist must verify his/her
certification status with the NC Board of Nursing, and thereafter on a
periodic basis, consistent with the nurse anesthetist‘s certification
renewal cycle. CRNAs are issued certificates of recognition. See
New York does not specify a specific method or process by which it
authorizes CRNAs to practice.
―The board may license for advanced practice as a certified
registered nurse anesthetist an applicant who furnishes evidence
satisfactory to the board….‖ [New Mexico Nursing Practice Act, sec.
61-3-23.3(A)]
―A registered professional nurse who wishes to practice as an
advanced practice nurse shall … [b]e certified by the Board as an
advanced practice nurse. ―[N.J.A.C. 13:37-7.1(c)]
CRNAs are a type of ―advanced practice nurse‖ [N.J.A.C. 13:377.1(a)] ―No person shall practice as an advanced practice nurse or
present, call or represent himself as an advanced practice nurse
unless certified in accordance with [the NPA].‖ [N.J.S. 45:11-46]
New Hampshire registered nurses seeking APRN licensure must
meet certain educational and administrative criteria. [New
Hampshire RSA, sec. 326-B:18(I)]
a certificate of recognition as a certified registered nurse
anesthetist.‖ [Nevada Admin. Code, sec. 632.530]
TYPE OF RECOGNITION
NPA and SBON R&R
NPA and SBON R&R
NPA and SBON R&R
NPA and SBON R&R
North Dakota
Ohio
Oklahoma
Oregon
January 2013
Page 9
PRIMARY SOURCE/
AUTHORITY FOR
RECOGNITION
STATE
―As of September 1, 1998, an individual shall meet the requirements
and receive a license as a CRNA in order to use the title CRNA,
Certified Registered Nurse Anesthetist or Nurse Anesthetist, and
engage in the scope of practice of a CRNA.‖ [Oregon Admin. Rules,
sec. 851-052-0020(1)]
" ‗Advanced Practice Registered Nurse‘ means a licensed
Registered Nurse … who has obtained a license as an Advanced
Practice Registered Nurse in one of the following roles: Certified
Registered Nurse Anesthetist, Certified Nurse-Midwife, Clinical
Nurse Specialist, or Certified Nurse Practitioner….‖ [Oklahoma
Statutes, sec. 567.3a(5)(e)]
―If the applicant for authorization to practice nursing as a certified
registered nurse anesthetist…has met all the requirements…the
Board of Nursing shall issue its certificate of authority to practice
nursing as a certified registered nurse anesthetist…which shall
designate the nursing specialty the nurse is authorized to practice.‖
[Ohio Revised Code, sec. 4723.42(A)]
CRNAs are a type of ―advanced practice nurse."
Applicants for advanced practice registered nurse licensure must
meet specific educational and administrative requirements
established by the North Dakota SBON R&R. [North Dakota Admin.
Code, sec. 54-05-03.1-04]
www.ncbon.com for an application and additional information.
TYPE OF RECOGNITION
SBON R&R
NPA
NPA and SBON R&R
NPA and SBON R&R
NPA and SBON R&R
NPA
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
January 2013
Page 10
PRIMARY SOURCE/
AUTHORITY FOR
RECOGNITION
STATE
". . . [N]urse anesthetists . . . holding such education and practice
credentials shall apply to the board for a certificate to practice as an
An applicant who meets specific educational and administrative
requirements established by the South Dakota Board of Nursing will
be certified by the Board to practice as a CRNA. [South Dakota
Admin. Rules, sec. 20:48:05:01]
― ‗License‘ means a current document issued by the board [of
nursing] authorizing a person to practice as an advanced practice
registered nurse ....‖ [Code of Laws of South Carolina, sec. 40-3320(36)]
CRNAs are a type of "advanced practice nurse."
The Rhode Island Board of Nurse Registration and Nursing
Education will issue a license to practice nurse anesthesia to
registered nurses who meet additional educational and
administrative requirements established by the Board. [Rhode Island
Rules and Regulations, part II, sec. 3.5]
Certification is the process through which the Board of Female and
Male Nurse Examiners of Puerto Rico recognizes that a nurse
meets the study and practice requirements to work in a specialized
area of nursing. [Act to Regulate the Practice of Nursing in the
Commonwealth of Puerto Rico, sec. 2(g)]
Pennsylvania does not specify a specific method or process by
which it authorizes certified nurse anesthetists to practice.
TYPE OF RECOGNITION
NPA and SBON R&R
NPA and SBON R&R
NPA and SBON R&R
SBON R&R
Texas
Utah
Vermont
Virginia
January 2013
Page 11
PRIMARY SOURCE/
AUTHORITY FOR
RECOGNITION
STATE
The Virginia Board of Nursing will license a nurse practitioner as a
CRNA if the nurse practitioner meets certain educational and
administrative requirements established by the Board. [Regulations
Governing the Licensure of Nurse Practitioners, part II, sec. 18 VAC
90-30-80]
CRNAs are a type of ‖nurse practitioner.‖
The Vermont SBON R&R refer to both ―endorsement‖ [Vermont
Admin. Rules, Ch. 4, Subch. 8(IV)(B)] and ―registration and
endorsement‖ [Vermont Admin. Rules, Ch. 4, Subch. 8(IV)(C)(1)]
as methods of recognition for APRNs in Vermont.
―The division [the Division of Occupational and Professional
Licensing] shall issue to a person who qualifies … a license … in
the classification of … advanced practice registered nurse – CRNA
without prescriptive practice.‖ [Utah Code Ann., sec. 58-31b301(2)(e)]
The Texas Board of Nursing will license a registered professional
nurse to practice as an advanced practice registered nurse if the
nurse meets certain educational and administrative requirements
established by the Board. [Texas Board of Nursing Rules and
Regulations, sec. 221.4]
advanced practice nurse...." [Tenn. Code Ann., Title 63, Chapter 7,
sec. 63-7-126 (b)]
TYPE OF RECOGNITION
NPA and SBON R&R
NPA and SBON R&R
NPA and SBON R&R
NPA and SBON R&R
NPA and SBON R&R
Virgin Islands
Washington
West Virginia
Wisconsin
Wyoming
January 2013
Page 12
PRIMARY SOURCE/
AUTHORITY FOR
RECOGNITION
STATE
A registered professional nurse applying for initial recognition as an
advanced practitioner of nursing must meet educational and
administrative requirements established by the Wyoming State
Board of Nursing. [Wyoming Admin. Rules and Regulations, ch. IV,
sec. 3]
CRNAs are a type of ―advanced practice nurse."
Wisconsin does not specify a specific method or process by which it
authorizes CRNAs to practice.
An applicant for licensure as an advanced practice registered nurse
must meet specific educational and administrative requirements set
forth in the Code of West Virginia sec. 30-7-1a. [Code of West
Virginia, sec. 30-7-1a]
CRNAs are a type of ―advanced practice registered nurse."
A registered nurse applicant for licensure as an advanced
registered nurse practitioner must meet specific educational and
administrative requirements set forth in the Washington SBON R&R.
[Washington Admin. Code, sec. WAC 246-840-340]
The Board of Nurse Licensure may issue a certificate to an
applicant to practice as a nurse anesthetist if that applicant meets
certain educational and administrative requirements established by
the Board. [Virgin Islands Code Ann., Title 3, sec. 96]
TYPE OF RECOGNITION
January 2013
Page 13
NPA: Nurse Practice Act
SBON R&R: State Board of Nursing Rules and Regulations
MPA: Medical Practice Act DOH: Department of Health Regulations
KEY:
January 2013
Page 14
California
Indiana
Puerto Rico
Tennessee
NPA
Iowa
Massachusetts
North Carolina
Pennsylvania
Virginia
SBON R&R
NPA and SBON R&R
Alabama
Alaska
Arizona
Arkansas
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Kansas
Kentucky
Louisiana
Maine
Maryland
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Jersey
New Hampshire
New Mexico
PRIMARY SOURCE/AUTHORITY FOR RECOGNITION
SUMMARY TABLE:
Dept. of Health
New York
January 2013
Page 15
Total:
4
NPA
5
SBON R&R
NPA and SBON R&R
North Dakota
Ohio
Oklahoma
Oregon
Rhode Island
South Carolina
South Dakota
Texas
Utah
Vermont
Virgin Islands
Washington
West Virginia
Wisconsin
Wyoming
43
1
Dept. of Health
Alaska
Georgia
Massachusetts
Ohio
4
13
Authorization
Alabama
Arizona
California
D.C.
Florida
Maryland
Michigan
Mississippi
New Jersey
Puerto Rico
South Dakota
Tennessee
Virgin Islands
Certification
2
Alabama
Nevada
Approval
4
Colorado
Iowa
Minnesota
Vermont1
Registration
5
Hawaii
Missouri
Nevada
North Carolina
Wyoming
Recognition
4
Indiana
New York
Pennsylvania
Wisconsin
No Additional
Method
January 2013
Page 16
* Some states appear in more than one column.
1
The Vermont SBON R&R refer to both ―endorsement‖ and ―registration and endorsement‖ as methods of recognition for APRNs in Vermont.
Alabama
Arkansas
Connecticut
Delaware
Idaho
Illinois
Iowa
Kansas
Kentucky
Louisiana
Maine
Montana
Nebraska
New Hampshire
New Mexico
North Dakota
Oklahoma
Oregon
Rhode Island
South Carolina
Texas
Utah
Virginia
West Virginia
Wisconsin
Washington
Total*: 26
Licensure
SUMMARY TABLE: TYPE OF RECOGNITION
4
11
Alabama
Arkansas
Colorado*
Delaware
Illinois
Maryland
New Jersey
Ohio
Rhode Island
Tennessee
Wisconsin
Advanced
Registered Nurse
Practitioner (ARNP)
Florida
Iowa
Virginia**
Washington
Advanced Practice
Nurse (APN)
January 2013
Page 17
1
Massachusetts
Nurse in the
Expanded Role
*States that have incorporated the APRN Consensus Model concepts of ―role‖ and ―population focus.‖
**Virginia uses the umbrella title ―nurse practitioner‖ or ―NP.‖
Advanced Practice
Registered Nurse
(APRN)
California
Connecticut
Georgia
Hawaii*
Idaho*
Kansas*
Kentucky*
Louisiana
Maine
Minnesota
Mississippi
Missouri
Montana
Nebraska
New Hampshire
North Carolina
North Dakota*
Oklahoma*
South Carolina
Texas*
Utah
Vermont
West Virginia*
Wyoming*
Total: 25
SUMMARY TABLE: UMBRELLA TITLE
10
No Umbrella Title
That Includes
CRNAs
Alaska
Arizona
Indiana
Michigan
Nevada
New Mexico
New York
Oregon
Pennsylvania
South Dakota
CNM, APN
CNM, ANP
CNM, RNP,
APRN
CNM, LNM,
APRN
Alabama
Alaska
Arizona
CNM, APN
CNM, LNM
CNM, APN
CNM, APRN
CNM, ARNP
CNM, APRN
CNM, APRN
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
American College of Nurse-Midwives, 2013.
CNM, APRN
California
Arkansas
Titles Used
State
Board of Nursing
Board of Nursing
Board of Nursing
Board of Nursing
Board of Nursing
Department of Health
Board of Nursing
Board of Registered Nursing
Board of Nursing
Board of Nursing
Board of Nursing
Joint Commission of the Board of
Nursing and Board of Medical
Examiners
Regulatory Board
No -- Independent Practice
Yes -- Supervisory State.
No.
All Rights Reserved.
Physician Agreement Required.
Collaborative Agreement Required for Overall Practice. Contractual
agreements are needed for prescriptive authority and enumerated
subsets of practice, such as ordering radiologic tests and emergency
protocols.
Collaborative Agreement Required for Overall Practice. Signed
agreements with a physician are not required if the CNM has an
agreement with a licensed health care delivery system.
Collaborative Agreement Required for Overall Practice. CNMs must
have an agreement with a physician if providing intrapartum care
and if they desire prescriptive authority.
Physician Involvement in
Physician Involvement in
Diagnosis & Treatment?
Prescribing?
Collaborative Agreement Required for Overall Practice.
SUMMARY of CERTIFIED NURSE-MIDWIFE REGULATORY STRUCTURES and PRACTICE ENVIRONMENTS in the UNITED STATES
CNM, APN
CNM, APN
CNM, ARNP
CNM, APRN
CNM, APRN
CNM, APRN
CNM, APRN
CNM
CNM, APRN
CNM
CNM, APRN
CNM, APRN
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
CNM, APPN
Idaho
No.
No - -Independent Practice
Collaborative Agreement Required for Overall Practice
No.
Collaborative Agreement Required for Overall Practice. No signed
agreement for overall practice is required if the CNM has hospital
privileges.
Agreements are only required for practice outside of a hospital or
ambulatory surgical treatment center.
Regulations must be promulgated
through the Board of Medical
Licensure and the Board of Nursing,
but the Board of Nursing has sole
authority to implement regulations.
Board of Nursing
Board of Nursing
Board of Registration in Nursing
Joint Committee
Board of Nursing
Board of Nuring
Board of Nursing
Board of Nursing
Board of Nursing
Board of Nursing
Department of Financial and
Professional Regulation
Board of Nursing
CNM, APRN
CNM, APRN
CNM, APN
CNM, APRN
CNM
CNM
Midwife, CNM
CNM
CNM, APRN
CNM, APN
CNM, APRN
CNM, NP
CNM
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
CNM, APRN
Missouri
Board of Medicine
Board of Nursing
Board of Nursing
Board of Nursing
Joint Committee
Board of Nursing
Board of Regents of the State
Department of Education
Public Health Division of State
Board of Medical Examiners
Board of Nursing
Board of Nursing
Department of Health & Human
Services, Division of Public Health
Board of Nursing
Board of Nursing
Collaborative Agreements Required for Overall Practice.
No.
Collaborative Agreement Required for Overall Practice
Collaborative Agreement Required for Overall Practice. Written
agreement, jointly agreed-upon protocols, or standing orders are
required.
CNM, APN
CNM, APN,
APRN
CNM
CNM, APRN
CNM, LNP
CNM, ARNP
CNM
CNM, APNP
CNM, APRN
South Carolina
South Dakota
Tennessee
Texas
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Utah
Midwife,
Licensed
Midwife
CNM, APRN
CNM
Rhode Island
Board of Nursing
Board of Nursing
Board of Examiners for Registered
Professional Nursing
Joint Committee
Committee of the Joint Boards of
Nursing and Medicine
Board of Nursing
Director of Occupational and
Professional Licensing within the
Department of Commerce
Board of Nurse Examiners
Board of Nursing
Board of Nursing
Joint Committee
No.
No.
Collaborative Agreement Required for Overall Practice. No
agreement required for the provision of out-of-hospital birth
services.
No.
APPENDIX F
May 15, 2013
State Capitol Complex
Building 1, Room 314W
Dear Mr. Sylvia:
I am the president of the American Association of Nurse Anesthetists (AANA), which
represents more than 45,000 nurse anesthetists (including Certified Registered Nurse
Anesthetists (CRNAs) and student nurse anesthetists) nationwide. The AANA submits
the following comments in support of the application submitted to the Performance
Evaluation & Research Division by the West Virginia Association of Nurse Anesthetists
and other West Virginia nursing groups.
CRNAs and Other APRNs Should be Permitted to Practice to the Full Extent of
Their Education and Training
As healthcare professionals, CRNAs practice according to their expertise, state statutes
and regulations, and institutional policy. The AANA supports the full scope of CRNA
practice as set forth in the AANA’s “Scope of Nurse Anesthesia Practice” and
“Standards for Nurse Anesthesia Practice” (at
http://www.aana.com/resources2/professionalpractice/Pages/Professional-PracticeManual.aspx).
State law should not restrict the ability of APRNs to practice to the full extent of their
education and training. Allowing practice by CRNAs and other APRNs without
unnecessary restrictions allows for greater patient access and cost-effective care, and is
also supported by the following:
•
The 2010 Institute of Medicine (IOM) report titled, The Future of Nursing: Leading
Change, Advancing Health (the IOM report, at
http://www.nap.edu/catalog.php?record_id=12956). The IOM report includes the
“key message” that: “Nurses should practice to the full extent of their education
and training.” [page 3-1] The IOM report further indicates “…regulations in many
states result in APRNs not being able to give care they were trained to provide.
The committee believes all health professionals should practice to the full extent
of their education and training so that more patients may benefit.” [page 3-10]
•
The “Consensus Model for APRN Regulation: Licensure, Accreditation,
Certification & Education” (July 2008) at
http://www.aacn.nche.edu/education/pdf/APRNReport.pdf recognizes APRNs as
2
“... licensed independent practitioners who are expected to practice within
standards established or recognized by a licensing body. Each APRN is
accountable to patients, the nursing profession, and the licensing board to
comply with the requirements of the state nurse practice act and the quality of
advanced nursing care rendered; for recognizing limits of knowledge and
experience, planning for the management of situations beyond the APRN’s
expertise; and for consulting with or referring patients to other health care
providers as appropriate.” [page 8]
The APRN consensus model further provides that an APRN as “is educationally
prepared to assume responsibility and accountability for health promotion and/or
maintenance as well as the assessment, diagnosis, and management of patient
problems, which includes the use and prescription of pharmacologic and nonpharmacologic interventions.” [page 7]
•
The National Council of State Boards of Nursing’s (NCSBN), the national
membership organization for all state boards of nursing, has developed a model
nurse practice act and model board of nursing rules (at
https://www.ncsbn.org/1455.htm) which incorporate the concepts for APRN
practice that are included in the APRN consensus model. Like the APRN
consensus model, the NCSBN models do not include restrictive physician
involvement in APRN practice.
CRNAs Provide High Quality, Cost-Effective Care
There is overwhelming evidence, most recently documented in studies released in
2010, that CRNAs provide superb, cost-effective anesthesia care. Nurse anesthetists
have been, since their inception, professionals who are acknowledged by the surgeons
with whom they practice to be experts regarding anesthesia. Nurse anesthetists have
been anesthesia specialists for nearly 150 years, and their safety records have been
outstanding.
The excellent safety record of CRNAs is reflected in a study titled, “No Harm Found
When Nurse Anesthetists Work without Supervision by Physicians,” which was
published in the August 2010 issue of Health Affairs, the nation’s leading health policy
journal. (The study is available at http://www.aana.com/optoutstudy/.) In that study,
which was conducted by Jerry Cromwell, a senior fellow in health economics at the
Research Triangle Institute (“RTI”) and Brian Dulisse, a health economist at RTI, the
authors analyzed nearly 500,000 hospitalizations in 14 opt-out states (i.e., the 14 states
that, at the time of the study, had opted out of the federal physician supervision
requirement for CRNAs; there are now a total of 17 opt-out states) and concluded that
allowing CRNAs to administer anesthesia services without physician supervision does
not put patients at risk. In fact, the authors found no increase in the odds of a patient
dying or experiencing complications in states that had opted out. The study also
3
compared outcomes by provider type and found that there are no differences in patient
outcomes of anesthesia services delivered by solo CRNAs, by solo anesthesiologists,
or by CRNAs being supervised by anesthesiologists.
An article that appeared in the May-June 2010 issue of the Journal of Nursing
Economic$ titled, “Cost Effectiveness Analysis of Anesthesia Providers” had similar
findings regarding the quality of CRNA care. (The article is available at
http://www.aana.com/advocacy/federalgovernmentaffairs/Documents/Value%20of%20C
RNA%20Care%20Study.pdf.) This article analyzed the cost-effectiveness of various
anesthesia models. The article also concluded that CRNAs can perform the same set
of anesthesia services as anesthesiologists and said that research studies have found
“no significant differences in rates of anesthesia complications or mortality between
CRNAs and anesthesiologists or among delivery models for anesthesia that involve
CRNAs, anesthesiologists, or both after controlling for other pertinent factors.…” The
article further noted that “[g]iven the low incidence of adverse anesthesia-related
complications and anesthesia-related mortality rates in general, it is not surprising that
there are no studies that show a significant difference between CRNAs and
anesthesiologists in patient outcomes.”
In addition, the article analyzed the cost-effectiveness of various anesthesia models and
concluded that “CRNAs acting independently provide anesthesia services at the lowest
economic cost.…” The article also concluded that models that require physician
oversight of CRNA practice are inefficient in areas of low demand such as rural
communities. In such communities, CRNAs acting independently is the only model
likely to result in positive net revenue.
For additional information regarding anesthesia quality of care studies, see the AANA
publication titled Quality of Care in Anesthesia. (Available at
http://www.aana.com/resources2/professionalpractice/Pages/Professional-PracticeManual.aspx.) The Quality of Care synopsis includes evidence that documents the high
quality of anesthesia care that CRNAs deliver.
Thank you for this opportunity to comment concerning this issue. Please do not
hesitate to contact Anna Polyak, RN, JD, the AANA’s Senior Director, State
Government Affairs, at 847-655-1131 or [email protected] if you have any questions
or require further information.
Sincerely,
Janice J. Izlar, CRNA, DNAP
AANA President
May 8, 2013
Elizabeth Baldwin, PNP, BC
Past President
West Virginia Nurses Association
PO Box 1946
Charleston, WV 25327
Dear Ms. Baldwin,
The American Nurses Association (ANA) is pleased to provide this letter as evidence for the research
review of advanced practice registered nurses (APRNs) underway by the Performance Evaluation and
Research Division (PERD) of the West Virginia Legislative Auditor’s Office. ANA applauds the Division
for addressing health care access for West Virginians. We understand the challenges faced in the state,
given that nearly half the population resides in rural settings with a significant number of residents with
high rates of chronic illness and or disabilities. Each year Americans are unable to acquire timely healthcare services either because of an inability to access primary care or because the provider no longer accepts
the patients’ insurance coverage, (such as Medicare). Although there is no single solution to address all of
the state’s health care challenges, the West Virginia Nurses Association (WVNA) has one solution…and
that is to remove restrictive regulatory language which would permit advanced practice registered nurses
(APRNs) to practice fully. The Centers for Medicare and Medicaid (CMS) examined National Provider
Identifier (NPI) data for distribution of select APRNs in rural areas based on their recorded zip code of
practice location. It revealed Nurse Practitioners (NPs) and Certified Registered Nurses (CRNAs) were
more likely to practice in rural locations in states with greater practice autonomy.
Decades of research has shown that APRNs provide care that is as high in quality and patient satisfaction as
that provided by physicians for the same type of services. All licensed individuals are accountable for their
actions / inactions and responsible for self regulation, making restrictions such as those that currently exist
in WV, unnecessary and burdensome. The ANA supports legislation that would remove the current WV
requirement for a collaborative practice agreement for APRNs to practice and prescribe. This unnecessary
approach is unsupported in any research. Other states with similar rural populations as WV have removed
restrictive practices in order to improve residents access to primary care. By aligning West Virginia
statute and rules with the national APRN Consensus model act, the state will be better positioned to meet
the needs of the medically underserved and focus on promoting healthier lifestyles. The ANA appreciates
the opportunity to provide comment.
Sincerely,
Janet Haebler MSN RN
Associate Director, State Government Affairs
American Nurses Association
Andrea Brassard DNSc, MPH, FNP
Senior Policy Fellow
American Nurses Association
West Virginia Affiliate of the American College of Nurse Midwives
c/o Gail Rock CNM
880 Trap Run Road
Friendsville, MD 21531
22 May 2013
Mr. John Sylvia
Director
Dear Mr. Sylvia and Performance Evaluation and Research Division Members:
I write on behalf of the West Virginia Affiliate of the American College of Nurse-Midwives (ACNM)
to support the application being submitted by the West Virginia Nurses Association (WVNA)
proposing the removal of barriers to practice for Advanced Practice Registered Nurses (APRNs) in
the state of West Virginia.
As a Certified Nurse Midwife (CNM) myself, this issue is close to my heart both personally and
professionally. CNMs are a kind of APRN. We are educated, certified, and licensed to practice our
profession within a defined scope of practice. Because of this education, certification, and licensure,
we do not require oversight by another professional, no matter how well-intentioned.
Research shows that APRNs provide safe, effective healthcare. Additionally, according to research by
the Federation of State Medical Boards, Nurse Practitioners and Nurse Midwives are less likely to be
named in a malpractice suit than are physicians, thus reducing the cost of frivolous law suits.
Physician oversight does not provide any additional level of safety for patients nor does it improve
the care that those patients receive. It does, however, create an additional burden on nurses and the
West Virginia nursing board.
Also relevant to this issue is the fact that Nurse Practitioners and Nurse Midwives are the providers
most likely to care for those patients covered by Medicaid, while many physicians have heavily
curtailed or even completely closed their Medicaid practice. Given the recent expansion of Medicaid
coverage in West Virginia, it behooves us to remove restrictions on nursing practice in order to
increase healthcare coverage, rather than create barriers to care for large numbers of West Virginia
citizens. Advanced Practice Nurses are hoping to continue to practice within the full scope of their
capabilities without unnecessary burdens on that practice.
West Virginians need expanded access to safe, quality healthcare. APRNs are exactly the practitioners
most able to provide this service at an affordable cost. The current language of the APRN law
restricts this practice. This is why we heartily endorse this proposal for removal of barriers to APRN
practice. We hope you will as well.
Very Truly Yours,
Gail Rock, CNM, MSN
President, West Virginia Affiliate of the American College of Nurse Midwives
May 13, 2013
I am a retired physician who has worked with nurse practitioners and nurse anesthetists
throughout my career. I am writing this letter of endorsement to support the application
being submitted by the West Virginia Nurses Association requesting removal of barriers
to practice for Advanced Practice Registered Nurses (APRNs) in West Virginia.
APRNs are educated, certified and licensed to practice their profession within a defined
scope of practice. Within that agreed upon scope they do not require oversight by
another professional. Research proves that APRNs provide safe, effective care.
Nurse Practitioners most often attend to Medicaid patients where physicians
increasingly do not. With the recent expansion of Medicaid in WV it behooves us to
make it easier for nurses to practice within the full scope of their capabilities without
adding any unnecessary burdens on that practice.
West Virginians need expanded access to safe quality healthcare. This is why I heartily
endorse this request to remove barriers to APRN practice, which restrict that access.
Sincerely,
Hedda L. Haning, M.D.
Charleston, WV 25314
May 22, 2013
I am writing this letter of endorsement on behalf of the West Virginia Primary Care Association
to support the application being submitted by the West Virginia Nurses Association requesting
removal of barriers to practice for Advanced Practice Registered Nurses (APRNs) in West
Virginia.
APRNs are educated, certified and licensed to practice their profession within a defined scope of
practice. They do not require oversight by another professional.
Research proves that APRNs provide safe, effective care. Additionally, according to research by
the Federation of State Medical Boards, Nurse Practitioners are less likely to be named in a
malpractice suit than physicians. Physician oversight does not provide any additional level of
safety for patients while creating an additional burden on nurses and the nursing board.
Nurse Practitioners most often attend to Medicaid patients where physicians increasingly do
not. With the recent expansion of Medicaid in WV it behooves us to make it easier for nurses to
practice within the full scope of their capabilities without adding an unnecessary burden on that
practice.
West Virginians need expanded access to safe quality healthcare. This is why we heartily
endorse this request for removal barriers to APRN practice, which restrict that access.
Respectfully submitted,
Louise Reese
Chief Executive Officer
1219 Virginia Street, E ♦ Charleston, WV 25301 ♦ 304.346.0032 ♦ Fax 304.346.0033
www.wvpca.org
May 8, 2013
I am writing this letter of endorsement on behalf of the West Virginia Association of Free Clinics
to support the application being submitted by the West Virginia Nurses’ Association requesting
removal of barriers to practice for Advanced Practice Registered Nurses (APRNs) in West
Virginia.
APRNs are educated, certified and licensed to practice their profession within a defined scope
of practice. They do not require oversight by another professional.
Research proves that APRNs provide safe, effective care. Additionally, according to research by
the Federation of State Medical Boards, Nurse Practitioners are less likely to be named in a
malpractice suit than physicians. Physician oversight does not provide any additional level of
safety for patients while creating an additional burden on nurses and the nursing board.
Nurse Practitioners most often attend to Medicaid patients where physicians increasingly do
not. With the recent expansion of Medicaid in WV it behooves us to make it easier for nurses to
practice within the full scope of their capabilities without adding an unnecessary burden on
that practice.
West Virginians need expanded access to safe quality healthcare. This is why we heartily
endorse this request for removal barriers to APRN practice, which restrict that access.
Very Truly Yours,
Linda West
Executive Director
______________________________________________________________________
1520 Washington Street; Charleston, WV 25311
304-414-5941
Beckley Health Right/Hinton Health Right; Eastern Panhandle Free Clinic; Ebenezer Medical Outreach;
Good Samaritan Clinic; Health Access; Mercer Charitable Clinic; Milan Puskar Health Right; Susan Dew Hoff Memorial Clinic;
West Virginia Health Right; Wheeling Health Right

PERD Application - West Virginia Nurses Association

Transcription

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