Your Voice is Important! What Legislators Need to Hear

1. Your Voice is Important!What Legislators Need to Hear Monday, February 10, 2014 Presented by Kathy Hutto, CNAP Lobbyist Jackson Walker L.L.P. and John Hubbard, CNAP Public Policy Director

2. Events Leading to SB 406 • 2005-2007 Moratorium • 2009-2011 Unsuccessful negotiations and initiatives • 2013 New dynamics • Nursing decision to pursue collaborative agreement • Medicine acknowledges deficiencies in current law • Perryman report • Sen. Nelson and Rep. Kolkhorst involvement

3. SB 406 Passes • Key dates • October 17-18, 2013 - BON and TMB adopt final rules • November 1, 2013 - Effective date of SB 406 • Practices must be in compliance with changes • January 1, 2014 - Boards issue FAQs • BON - http://www.bon.texas.gov/practice/faq-presauthSB406.html • TMB - http://www.tmb.state.tx.us/page/prescriptive-delegation

4. What Is Next and How Do We Get There? • October 25, 2013 – CNAP Retreat – Leadership of all APRN organizations bring priorities. • Started with 27 Priorities!! • Common themes: • Independent practice • Practice-related issues • Prescription-related issues • Higher-education related issues • Third-party reimbursement issues

5. Why Not Independent Practice in 2015??!!! Political Reality – Legislature thinks we got a BIG GULP Look at 2009 and 2011 Leadership wanted continued forward movement and changes to benefit as many practices as possible

6. 8 Priorities • Ensure that APRNs have the ability to contract directly with insurance providers and serve as Primary Care Providers whether the delegating physician is in network or a contracted provider. • Expand authority to prescribe Schedule II medications to Psychiatric APRNs and APRNs providing Palliative Care. • SB 406 clean- up: Clarify that APRNs with at least three years of delegated prescriptive authority with the same physician can go directly to quarterly face-to-face meetings. Other clarifications, if needed. • Allow APRNs to sign Do Not Resuscitate Orders (DNRs).

7. 8 Priorities (cont’d) • Allow APRNs to sign death certificates. • Eliminate having physician identifiers included on APRN-authored prescriptions; i.e. eliminate physician’s name, address, phone number & DEA number from the prescription. • Stop any new restrictions on APRNs’ ability to provide pain management services (not related to prescribing Schedule IIs). • Resolve issue relating to the number of prescription refills for Controlled Substances, Schedules III-V, that APRNs can write; Statute says “the prescription, including a refill…not to exceed90 days”.

8. Good News Resolution of 90 day issue is near! 7 priorities are more than enough! DO NOT EXPECT OR WANT YOU TO TRY TO DISCUSS ALL 7 TODAY! Key message is simple.

9. APRNs Can Improve Access to Health Care • Texas faces a severe shortage of primary care physicians. • APRNs are a safe, cost-effective solution as they already diagnose & prescribe, but face unnecessary restrictions. • Practical solutions are needed in Texas law to address the problems that delay and prevent APRNs from caring for Texans.

10. The Priority Issue:Authorizing APRNs as PCPs Ensure that APRNs have the ability to contract directly with insurance providers and serve as their patient’s Primary Care Provider whether or not the delegating physician is in-network or a contracted provider.

11. Authorizing APRNs as PCPs:The Current Situation Two provisions of current Texas law state that a managed care organization (MCO) may not refuse a request made by an in-network physician and an advanced practice registered nurse (APRN), authorized by the physician to provide care, to identify the APRN as a network provider. Section 843.312 of the Texas Insurance Code Section 1301.052 of the Texas Insurance Code

12. Authorizing APRNs as PCPs:The Current Situation • Texas faces a physician shortage. As a matter of fact, according to the Texas Medical Association (TMA) fewer than 1/3 of all doctors are willing to accept new Medicaid patients, down from 2/3 in 2000. • As a result of this situation, a provision was added to SB 406 with the intent to allow APRNs to be a PCP for Medicaid managed care patients even if the physician who delegates prescriptive authority to them is not in that Medicaid plan. • This provision was agreed to by HHSC and TDI staff, as well as TMA, TAFP, TACHC, CNAP, TNP, and TNA.

13. Authorizing APRNs as PCPs:The Problem Despite the agreed upon changes in SB 406 Medicaid managed care plans deny credentialing APRNs when the delegating physician is not an in-network provider. In addition, HHSC is not changing the Uniform Managed Care Contract because HHSC staff think SB 406 does not supersede the in-network requirements for APRNs supervising physicians found in the Insurance Code. As a result, APRNs willing to serve the Medicaid population are unable to do so, leaving many people unable to find the health care they need. This is especially true of the elderly, people with disabilities and children – the most vulnerable Texans.

14. Authorizing APRNs as PCPs:The Solution The Insurance Code needs to be amended to require APRNs be recognized as PCPs whether the delegating physician is in-network or not.