Michigan Legislative Update: APRN Scope of Practice SB 481/HB 4774

1. Michigan Legislative Update: APRN Scope of PracticeSB 481/HB 4774 June 22, 2012 Created from MICNP Website Information and other sources as sited Ann Sheehan, DNP, RN, CPNP

2. NP PRACTICE IN MICHIGAN • As of January 2010, 6,486 RNs were certified as advanced practice registered nurses (APRNs); of those, more than half (3,778) were nurse practitioners. • 59% MI NPs practice in primary care settings • Health care needs are overwhelming providers and this will only get worse as health care reform rolls out • Critical need for NP practice advancement • Gov. Snyder’s health care agenda

3. NP PRACTICE REGULATIONS EDUCATION • Nurse practitioners in Michigan are RNs who hold a master’s degree in nursing, with a certificate in advanced practice nursing. • Future NPs will substantiate entry into practice with a practice doctorate (DNP). CERTIFICATION/LICENSURE • Michigan Public Health Code governs the practice of nursing • Because NPs are licensed as RNs, their scope of practice is broadly defined through this statute • no separately defined scope of practice exists for NPs in Michigan law. • MI NPs are NOT protected under licensure to provide an advanced scope of practice.

4. MI NP SCOPE OF PRACTICE • The Occupational Regulation Sections of the Michigan Public Health Code Act 368 of 1978 serves as the legal scope of practice statement • Registered Nurses are licensed to practice independently within this scope. When doing medically delegated functions such as prescribing, supervision by the delegating physician is required. • "Practice of nursing" means the systematic application of substantial specialized knowledge and skills derived from the biological, physical, and behavioral sciences, to the care, treatment, counsel, and health teaching of individuals who are experiencing changes in the normal health processes or who require assistance in the maintenance of health and the prevention or management of illness, injury, or disability. ( PHC 333.17201)

5. In the Michigan Public Health Code, all health professionals have a broad definition of their practice and definitive tasks or roles are not encoded for any specialty area for any health occupation. Therefore, the State of Michigan does not yet delineate by law a scope of practice specific to APRNs.  All nurses are responsible and accountable for recognizing the limits of their knowledge and skill. • In the state of Michigan, APRNs practice within a scope of practice defined by their specialty education and training and also the client population within the practice environment.  • NP specialties should refer to their own professional organization and/or certifying body for specific scope of practice guidance

6. WHY IS THIS A PROBLEM? • PAYER ISSUES • NPS can be reimbursed by Medicare, Medicaid, Medicare secondary payers, and commercial payers based on collaborative agreement • LEGAL ISSUES • Medicare defines collaboration • a process in which a NP works with a physician to deliver health care services within the scope of the practitioner’s professional expertise, with medical direction and appropriate supervision as provided for in jointly developed guidelines or other mechanism as defined by the law of the state

7. ACCESS ISSUES • Access to care barriers, especially for vulnerable populations • Prescriptive barriers • Commercial payer barriers • NATIONAL CONGRUENCY ISSUES • Other states • Alphabet soup

8. CHANGES TO NURSE PRACTITIONER PRACTICE IS NOT only a STATE ISSUE BUT also A NATIONAL AGENDA ISSUE • Institute of Medicine • RWJF • ANA AND AANP • NP Roundtable • Numerous specialty nursing organizations

9. FUTURE NP PRACTICE • Proposed changes to a healthcare professions’ scope of practice elicits debates and strong words---turf wars. • What is lost among the competing arguments are the most important issues of whether proposed changes will better protect the public and enhance consumers access to competent healthcare services. • IOM and Pew Healthcare Commission call for addressing scope ONLY through whether or not the profession can provide a proposed service in a safe and effective manner---any issue not addressing this question has “no relevance for discussion.”

10. IOM AND PEW FOUNDATIONS FOR PRACTICE SCOPE CHANGES • An established history of the practice scope within the profession • Education and trainings • Supporting evidence • Appropriate regulatory environment * If a profession can provide supporting evidence in theses areas, the proposed change in scope is likely to be in the public’s best interest

11. AANP Historical Timeline http://www.aanp.org/about-aanp/historical-timeline

12. Aprn AUTHORITY TO PRACTICE • LICENSURE • Granting of authority to practice • ACCREDITATION • Formal review and approval by a recognized agency of educational degree or certification programs in nursing or nursing-related programs • CERTIFICATION • formal recognition of the knowledge, skills, and experience demonstrated by the achievement of standards identified by the profession. • EDUCATION • formal preparation of APRNs in graduate degree-granting or postgraduate certificate programs.

13. MICHIGAN APRN Legislation • PRIMARY FOCUS OF LEGISLATIVE IS TO AMEND THE PUBLIC HEALTH CODE TO ACHIEVE NATIONAL CONGRUENCY • LICENSURE AND SCOPE • SENATE BILL 481/ HB 4774 • Separate NP license and Fees (p. 6-7) • Role definition of each APRN group with population (p.8-9) • Scope statements (p. 10) • Licensure connection to Education and Certification requirements and scope of practice (p. 8, 11-12) • Develop task force/ subcommittee within BON to develop public guidelines for scope of practice, handle disciplinary actions, oversee APRN licensure requirements, reinstatements. (p.14-15) • Referral to speech therapy (p.16) • Independent prescriptive authority including Schedule 2-5 if meeting educational requirements with DEA # recognition (p. 17-21)

14. SB 481/HB 4774 Bullet points • Define APRNs based on national standards • NP • NMW • CNS • Authorize APRNs to practice to the full extent of education and board certification • Improve consumer choice and direct access to qualified providers • Remove unnecessary barriers, which is consistent with Gov. Snyder’s health care agenda for MI

16. SENATE BILL 481 28th District: GRAND RAPIDS 12th District: OAKLAND Senator Mark Jansen: (R) INTRODUCER Senator Jim Marleau (R): HEALTH POLICY COMMITTEE CHAIR

18. HEALTH POLICY COMMITTEE • MARLEAU (R) NORTH OAKLAND (12TH) • ROBERTSON (R) EAST GENESEE (26TH) • EMMONS(R) MONTCALM (33RD) • HUNE (R) LIVINGSTON (22ND) • JONES (R) BARRY COUNTY (21ST) • SCHUITMAKER (R) KALAMAZOO COUNTY (20th) • WARREN (D) WASHTENAW (18TH) • GLEASON (D) WEST GENESSEE (27TH)

19. Scope of Practice for Advance Practice Nurses – The Players • Support by Michigan Nurses Association (& sub-groups), Michigan Primary Care Association • MI APRN Groups • MICNP • MI NAPNAP • MI CNS Group • MI NMW Group • Neutral MI APRN Groups • Nurse Anesthetists (MANA) • Some of MHA membership supportive of concept • Opposition from Physician groups • Michigan State Medical Society (MDs) • Michigan Osteopathic Association (DOs) • Michigan Academy of Family Physicians (Prim. care MDs)

20. Scope of Practice for Advance Practice Nurses – Points of Debate • Opposition Arguments • Current law already allows APNs to prescribe under supervision and delegation • Education and training should determine scope, not laws • Changing current law would not improve access, quality or cost of care, there has been no demonstrated proof of such • Reducing educational requirements for prescribers could patient health at risk • Supporter’s Arguments • Increase access to health care (rural areas) • Improve Michigan’s ability to attract and retain nurses • Improve health care quality and reduces costs • Transparency and Responsibility – APNs are willing to accept all of the responsibility for everything in their scope of practice

21. Patient Safety & Quality Findings • Health Affairs (August 2010) • Recommends CMS allow CRNA’s to practice without supervision and dispense with ‘opt-out’ process • Nursing Economics (May-June 2010) • Makes quality and access argument in support of expanded CRNA scope of practice • Institute of Medicine (Oct. 2010 Report Brief) • Supports federal removal of practice barriers for APNs • Says CMS should reimburse APNs the same as physicians for the same care • Calls for FTC investigations into anti-competitive scope of practice rules

22. Florida APRN House Bill • Removal of supervisory language for APRNs and the number of APRNs that one physician can supervise • Letter from the Federal Trade Commission to the Florida House Chairman sent March 22, 2011 http://www.ftc.gov/os/2011/03/V110004campbell-florida.pdf

23. Texas APRN Senate BillS • Remove physician supervision and delegation requirements • Allow APRNs to practice to the full extent of their education and training • Grant diagnostic and prescription writing authority to APRNs http://www.ftc.gov/os/2011/05/V110007texasaprn.pdf

24. Federal trade commission “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. Competition is at the core of America’s economy, and vigorous competition among sellers in an open marketplace gives consumers the benefits of lower prices, higher quality products and services, more choices, and 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 focus of FTC law enforcement, research, and advocacy.”

25. Ftc (continued) “Recently, FTC staff have urged several states to reject or narrow restrictions that limit health care access and raise prices to consumers by limiting competition among health care providers and professionals. In particular, staff have examined apparently excessive restrictions on the scope of practice of ARNPs. A recent report by the Institute of Medicine (IOM) on the Future of Nursing recognizes the importance of this competition perspective and, in particular, the Commission’s expertise and experience in addressing undue and anticompetitive restrictions on the scope of nursing practice.”

26. FTC Conclusions for FL & TX • Physician supervision of APRNs imposes increased cost to health care for TX and FL consumers • These bills would improve access and increase choice in health care • Find no evidence that the current restrictions are required to address patient harm • Recommend procedures that require supervision be handled at the institution level for all levels of providers

27. Further Points of Debate within MI APRN groups • The Nurse Anesthetists (MANA) made a last minute call to MICNP regarding their disagreement with NAs not being defined in the bill • Requested to be defined in the bill or they would testify against the bill • This came on the eve of Senate Health Policy Committee Hearing • The consensus from all of the Adv. Practice Organizations was to agree to talk about adding an amendment after the bill was though the HP committee

28. Senate health policy hearing • Originally scheduled for Thursday, May 30, 2012 • Cancelled at the last minute • Rescheduled for Wednesday, June 6, 2012 • Nancy George, PhD (MICNP President-elect) • Joanne Pohl, PhD, ANP-BC (U of M, College of Nursing) • Dan McMurtrie, MD • Lynn Rife (MI ACNM) • Denise O’Brien (MI ACNS)

29. Where do we go from here? • Senate HP Committee will have a work group over the summer • APRN groups are welcome to come to these work group meetings • Every APRN/Faculty/Nurse/HC Consumer needs to continue to touch base with Senators about this bill to be sure it gets out of the HP committee in the Fall and to the Senate floor for a vote. • When I say everyone I do mean YOU!

30. www.micnp.org Advocacy Day October 3, 2012 Lansing, MI